Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Covenant Living Of Golden Valley Care & Rehab Ctr during CMS and state inspections, most recent first.
A resident was discharged without a review of discharge instructions or medications with the resident or their representative, resulting in the resident being sent home with another resident's medications. Staff interviews and documentation confirmed that required procedures for medication review and discharge planning were not followed, and the discharge paperwork lacked necessary signatures.
Two residents' confidentiality was breached when pharmacy medication cards containing protected health information for one resident were mistakenly sent home with another resident at discharge. Staff interviews revealed that the error was not initially recognized, and the family of the discharged resident confirmed receipt of the incorrect medications.
A resident with chronic pain did not receive prescribed gabapentin and lidocaine gel for over nine days due to the facility's failure to obtain the medication from the pharmacy. Despite being aware of the issue, the DON and RN could not resolve it, and the nurse practitioner was not informed, preventing alternative pain management. The pharmacy claimed the medication was delivered and signed for, but it was not found in the facility.
Failure to Review Discharge Instructions and Medication Disposition
Penalty
Summary
The facility failed to ensure proper discharge procedures for a resident, resulting in the resident being sent home with another resident's medications. Specifically, the discharge paperwork for the resident did not include evidence that discharge instructions or medications were reviewed with the resident or their representative. The medication administration records showed that the medications sent home (sulfamethoxazole and lisinopril) were not prescribed for the discharged resident, but for another resident. The discharge form lacked a nurse's signature as a witness, and the medication sticker for the other resident's medication was included in the discharged resident's record. Interviews with facility staff revealed a lack of awareness regarding the medication error, and the process for reviewing discharge paperwork and medications was not followed. The family of the discharged resident confirmed that no review of discharge paperwork or medications occurred at the time of discharge, and the medications were simply handed over in a bag. Facility policy required review and documentation of discharge planning and medication disposition, but these steps were not completed, leading to the error.
Failure to Maintain Confidentiality of Resident Medical Records
Penalty
Summary
The facility failed to maintain the confidentiality of clinical records for two residents when two pharmacy medication cards belonging to one resident were sent home with another resident upon discharge. Specifically, a resident was discharged with medication cards for sulfamethoxazole and lisinopril that were prescribed for a different resident. The medication administration records confirmed that the discharged resident did not have orders for these medications, while the other resident did. The pharmacy cards contained protected health information, including the resident's full name, physician information, medication details, and the conditions for which the medications were prescribed. Interviews with facility staff revealed a lack of awareness regarding the error. The assistant director of nursing stated that nurses are responsible for reviewing medications with residents at discharge but was unaware that the wrong medications had been sent. The registered nurse denied sending the incorrect medications, and the director of nursing was not initially aware of the incident but later verified the error through documentation. The family of the discharged resident confirmed receipt of the other resident's medications and provided photographic evidence.
Failure to Administer Ordered Pain Medication
Penalty
Summary
The facility failed to provide physician-ordered medication in a timely manner for a resident, leading to a deficiency in pharmaceutical services. The resident, who was cognitively intact and had a complex medical history including chronic pain syndrome and ulcerative colitis, was admitted with orders to receive a gabapentin and lidocaine topical gel for pain relief. However, the medication was not administered as scheduled for over nine days, from the date of admission through February 13, 2025. This lapse in medication administration was due to the facility's inability to obtain the gel from the pharmacy, despite it being ordered and reportedly shipped. Interviews revealed that the registered nurse and the director of nursing were aware of the issue, with the latter expressing frustration over the pharmacy's inability to provide the compound. The nurse practitioner was not informed of the medication's unavailability, which prevented alternative pain management solutions from being explored. The pharmacy director confirmed that the gel was shipped and signed for by a staff nurse, but it was never located within the facility. The facility's policy on handling such situations was not provided during the survey, indicating a possible gap in procedural adherence or documentation.
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What surveyors actually found near you
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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 Golden Valley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Courage Kenny Rehabilitation Institutes Trp | 1.2 mi | ★★★★★ | 7 | 1 |
| The Villas At Brookview | 1.3 mi | ★★★★★ | 26 | 1 |
| Good Samaritan Ambassador | 1.6 mi | ★★★★★ | 2 | 0 |
| The Villas At Robbinsdale | 1.6 mi | ★★★★★ | 5 | 1 |
| The Terrace At Crystal Llc | 1.8 mi | — | 65 | 4 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.