Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Covenant Village Care Center during CMS and state inspections, most recent first.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
A nurse failed to use both gown and gloves, as required by Enhanced Barrier Precautions, while administering medications and a bolus feeding through a G-tube to a resident with dysphagia, CVA, and CHF. This omission was observed during care, and both the nurse and DON confirmed that facility policy required full EBP for residents with indwelling devices.
The facility did not prevent the use of unnecessary psychotropic medications or medications that could restrain a resident's ability to function, resulting in residents receiving drugs without adequate justification or in a manner that could limit their functional abilities.
Two residents did not have comprehensive, person-centered care plans addressing the use of bed side rails, despite observations and physician orders indicating their use. Staff interviews and record reviews confirmed that neither mobility rails for a resident with spastic hemiplegia nor padded side rails for a resident with a seizure disorder and severe cognitive impairment were specifically included in their care plans, contrary to facility policy.
The facility did not ensure proper documentation and tracking of medication patch application and removal for a resident, failed to monitor and document follow-up dental care for another resident with cognitive impairment, and did not maintain required records for fluid intake and lab result communication for two additional residents. These deficiencies were identified through direct observation, interviews, and record reviews, highlighting lapses in documentation and care coordination.
The facility did not have an effective system in place to periodically reconcile all controlled substances, as confirmed by both the DON and the consultant pharmacist. Although policies required regular monitoring and reconciliation, these were not followed, leading to a risk of diversion or unaccounted medications.
Surveyors identified that the facility's medication administration practices resulted in a medication error rate of 5 percent or greater, exceeding the regulatory limit.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
A resident with multiple diagnoses, including depression and hallucinations, had their Seroquel dose increased without documented informed consent. The resident was cognitively intact and regularly saw a psychiatrist, but the DON confirmed that no new consent was obtained for the higher dose, contrary to facility policy and pharmacist expectations.
The facility failed to act on a pharmacist's recommendations to add specific durations to PRN psychotropic medications for two residents. One resident with severe cognitive impairment was prescribed lorazepam without a stop date, and another with chronic pain syndrome was given Ativan without a stop date. Despite recommendations, the physician did not respond, and the orders remained unchanged, leading to a deficiency in medication management.
The facility failed to specify the duration for PRN antianxiety medications for two residents, contrary to its policy. One resident with severe cognitive impairment and another with intact cognition received PRN orders for lorazepam and Ativan, respectively, without a stop date. Interviews with staff revealed a lack of awareness and oversight regarding the missing stop dates, leading to non-compliance with the facility's policy and regulatory requirements.
The facility failed to store respiratory equipment properly and did not use enhanced barrier precautions during wound care for two residents. Oxygen tubing was not stored in a plastic bag as required, and staff did not use gown and gloves during wound care, contrary to facility policy. Interviews confirmed the expectations for proper storage and use of EBPs were not met.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Use Enhanced Barrier Precautions During G-Tube Care
Penalty
Summary
A deficiency occurred when a nurse failed to follow proper infection control practices for a resident with a gastrostomy tube (G-tube) during medication administration and bolus feeding. The nurse wore only gloves, omitting the required gown, despite the facility's policy and procedure on Enhanced Barrier Precautions (EBP) that mandates both gown and glove use for high-contact care activities involving residents with indwelling medical devices such as G-tubes. This was observed during a medication administration task. The resident involved had a medical history including dysphagia, cerebrovascular accident (CVA), and congestive heart failure (CHF), and was considered at high risk for infection due to the presence of the G-tube. Interviews with the nurse and the Director of Nursing confirmed that EBP, including both gown and gloves, were expected for such care activities, and that wearing only gloves was not sufficient according to facility policy. The failure to adhere to these precautions was directly observed and confirmed through staff interviews and policy review.
Unnecessary Use of Psychotropic Medications
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications or the use of medications that may restrain a resident's ability to function. This deficiency indicates that residents were administered psychotropic drugs without adequate justification or in a manner that could limit their functional abilities. The report does not provide specific details about the residents involved, their medical histories, or their conditions at the time of the deficiency.
Failure to Develop and Implement Person-Centered Care Plans for Bed Rail Use
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents regarding the use of bed side rails. For one resident with spastic hemiplegia and muscle weakness, mobility rails were observed in use on both sides of the bed, but there was no care plan specifically addressing their use. Both the LVN and MDS nurse confirmed that the resident's care plan did not include a dedicated section for mobility rails, despite their role as an assistive device requiring monitoring for safe usage. The DON also acknowledged that the use of mobility rails was only listed as an intervention under another care plan and not as a separate, specific plan as required. For another resident with a history of seizure disorder and severe cognitive impairment, padded side rails were observed in use during multiple observations. The resident's physician orders included seizure precautions and specified the use of padded rails. However, review of the care plan revealed that the intervention for padded side rails was not included. The LVN and DON both stated that the care plan should have included this intervention to ensure staff awareness and proper care for the resident. Facility policy requires that comprehensive, person-centered care plans be developed within a specified timeframe after assessment and be revised as resident conditions change. The lack of specific care plans for the use of mobility and padded side rails for these two residents was confirmed through interviews, record reviews, and direct observation, constituting a failure to meet the facility's own policies and regulatory requirements.
Failure to Adhere to Professional Standards in Medication, Dental, and Clinical Follow-Up Documentation
Penalty
Summary
The facility failed to ensure that care and services were provided in accordance with professional standards of quality for three of five sampled residents. For one resident with a history of hypertension and shoulder pain, a lidocaine 4% patch was applied without dating, timing, or initialing the patch at the time of administration. The nurse was unable to confirm when the previous patch was removed, and there was no documentation of patch removal in the Medication Administration Record (MAR). The nurse also stated that patches were never dated or initialed, and there was no clear method to determine when patches were removed, contrary to facility expectations and medication guidelines. Another resident, who had moderate cognitive impairment and was missing upper front teeth, reported that a dental mold for new partial upper dentures had been completed months prior, but no follow-up had occurred. The Social Service Director (SSD) did not have a system in place to monitor or track follow-up dental appointments and was unfamiliar with the dental notes indicating the need for follow-up. The SSD acknowledged not maintaining a list of residents requiring follow-up visits and not documenting updates or referrals in the resident's chart, despite being responsible for coordinating resident care. Additionally, the facility failed to maintain a running total of daily fluid intake for another resident, and a potassium lab result for a different resident was not communicated to the prescriber, with no evidence of clinical follow-up or intervention. These failures were identified through observation, interview, and record review, and were directly related to lapses in documentation, communication, and adherence to professional standards of care.
Failure to Periodically Reconcile Controlled Substances
Penalty
Summary
The facility failed to ensure proper pharmaceutical services were provided to meet the needs of residents by not having an effective system in place to periodically reconcile all controlled substances. During interviews, the DON stated that while medications of discharged or deceased residents were stored in a locked box until destruction, there was no process for periodic reconciliation of controlled substances. The DON acknowledged the absence of such a system and recognized its importance in preventing missing drugs. The Registered Pharmacist also confirmed that there was no process for periodic reconciliation and emphasized the necessity of this practice to ensure all medications were properly accounted for. A review of the facility's policies and procedures revealed that they required periodic review and updating of controlled medication monitoring by the DON and consultant pharmacist, as well as regular reconciliation of controlled substance inventory to identify loss or diversion. However, these procedures were not being followed, as evidenced by the lack of a system for periodic reconciliation. 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.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
A medication error rate of 5 percent or greater was identified during the survey. This indicates that the facility failed to ensure that the administration of medications was performed with an acceptable level of accuracy, resulting in a higher than permitted rate of medication errors among residents. The deficiency was based on direct findings by surveyors regarding the facility's medication administration practices, as evidenced by the calculated error rate exceeding the regulatory threshold.
Failure to Properly Label and Secure Medications
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions resulted in a failure to meet regulatory standards for the labeling and secure storage of medications and biologicals within the facility.
Failure to Obtain Informed Consent for Psychotropic Medication Dose Increase
Penalty
Summary
The facility failed to obtain informed consent prior to increasing the dosage of Seroquel, an antipsychotic medication, for a resident with diagnoses including blindness, hypothyroidism, arthritis, depression, visual hallucinations, and anxiety. The resident was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 13, and had regular virtual appointments with a private psychiatrist, which were arranged by the Social Services Director and attended by the resident's family. The resident's Medication Administration Record showed an increase in Seroquel dosage from 25 mg in the morning and 50 mg at night to 50 mg twice daily, as recommended by the psychiatrist. Despite this change, the last documented informed consent for Seroquel was obtained prior to the dosage increase, and there was no documentation of informed consent for the new, higher dose. The Director of Nursing confirmed that no informed consent was obtained for the increased dosage, and the Registered Pharmacist stated that informed consent is required before increasing a medication dose. Facility policy also indicated that psychotropic medication management is an interdisciplinary process involving the resident and their representative.
Failure to Act on Pharmacist's Recommendations for PRN Psychotropic Medications
Penalty
Summary
The facility failed to act upon the pharmacist's recommendation to add a specific duration to as-needed psychotropic medication orders for two residents, leading to a deficiency in medication management. Resident #37, who was admitted with a history of severe cognitive impairment and anxiety, was prescribed lorazepam on an as-needed basis without a stop date. Despite the pharmacist's recommendation in March 2024 to include a duration for the medication, the physician did not respond, and the order remained unchanged. Interviews with the nurse practitioner and pharmacist confirmed the lack of action on the recommendation, and the Director of Nursing acknowledged the oversight. Similarly, Resident #11, with a history of chronic pain syndrome and anxiety, was prescribed Ativan on an as-needed basis without a stop date. The pharmacist recommended in April 2024 that a 14-day stop date be added, but the physician did not follow up on this recommendation, citing the family's preference to maintain the medication regimen. The physician admitted to not documenting the decision to keep the medication order unchanged in the resident's chart, and the Director of Nursing was unaware of the missing stop date. The facility's policy required that medication regimen review recommendations be acted upon within 30 days, but this was not adhered to in these cases. The administrator expected staff to follow the policy and for physicians to address pharmacy recommendations, but this expectation was not met, resulting in the deficiency. The lack of action on the pharmacist's recommendations for both residents highlights a failure in the facility's medication management process.
Failure to Specify Duration for PRN Antianxiety Medications
Penalty
Summary
The facility failed to comply with its policy on psychotropic medication use by not specifying the duration for as-needed (PRN) antianxiety medications for two residents. Resident #37, who was admitted with a history of major depressive disorder and anxiety, had a PRN order for lorazepam without a stop or discontinue date. Similarly, Resident #11, with a history of chronic pain syndrome and anxiety, had a PRN order for Ativan without a specified duration. Both residents received these medications during their assessment periods, but the orders did not comply with the facility's policy that requires a stop date or duration for PRN psychotropic medications. Interviews with facility staff, including the Nurse Practitioner, Pharmacist, Director of Nursing, and Administrator, revealed a lack of awareness and oversight regarding the missing stop dates for these PRN orders. The Nurse Practitioner acknowledged the requirement for a stop date within 14 days, and the Pharmacist stated that recommendations for specifying the duration were typically made during medication reviews. However, these recommendations were overlooked, leading to non-compliance with the facility's policy and regulatory requirements. The Director of Nursing and Administrator both expressed expectations that staff follow the policy, but they were not aware of the oversight until it was brought to their attention.
Inadequate Infection Control Practices
Penalty
Summary
The facility failed to adhere to its policy regarding the storage of respiratory equipment for a resident with a history of acute and chronic respiratory failure and COPD. The policy required that oxygen cannulae and tubing be stored in a plastic bag when not in use. However, during an observation, the oxygen tubing was found resting on the concentrator instead of being stored in the designated bag. Interviews with the LVN, CNA, DON, and Administrator confirmed that the expectation was for the tubing to be stored properly to prevent infections. Additionally, the facility did not implement enhanced barrier precautions (EBPs) during wound care for a resident with a history of malignant neoplasm of the stomach and rhabdomyolysis. The facility's policy required the use of gown and gloves during high-contact activities, including wound care. Despite this, LVN and RN did not use EBPs during the wound care, believing it was unnecessary due to the wound's small size and lack of drainage. The ICPO and DON later confirmed that EBPs should have been used, as the wound required daily dressing changes, and the staff should have followed the policy.
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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 Turlock
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Turlock Nursing & Rehabilitation Center | 0.1 mi | ★★★★★ | 0 | 0 |
| Brandel Manor | 0.2 mi | — | 0 | 0 |
| North Starr Postacute Care | 0.9 mi | ★★★★★ | 1 | 0 |
| Main West Postacute Care | 1.8 mi | ★★★★★ | 1 | 0 |
| Ceres Postacute Care | 9.5 mi | ★★★★★ | 2 | 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 June 2026) and official state health department websites.