Cycle 1
Health 2025-05-22 · Fire 2025-05-22
2 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Golden Valley, MN
Covenant Living Of Golden Valley Care & Rehab Ctr
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
5825 St Croix Avenue, Golden Valley, MN
(763) 732-1415
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
88
Certified beds
Average residents
68
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Covenant Living
Operator or chain grouping
Approved since
1986-07-01
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
15 facilities
Chain averages 4 overall / 4 health / 4 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
1.25
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
1.10
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.45
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
4.80
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
2.35
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
4.39
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.84
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.39
CMS adjusted RN staffing hours
Adjusted total hours
5.31
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
22%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
488
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
69.02
Composite VBP score used to determine payment impact.
Payment multiplier
1.0219
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.85
Baseline 22.09% · Performance 20.90% · Measure score 1.85 · Achievement 1.15 · Improvement 1.85
Healthcare-associated infections
8.52
Baseline 5.31% · Performance 5.29% · Measure score 8.52 · Achievement 8.52 · Improvement 0.25
Total nurse turnover
10
Baseline 42.31% · Performance 19.70% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
7.24
Baseline 4.9 hours · Performance 5.14 hours · Measure score 7.24 · Achievement 7.24 · Improvement 2.20
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.34% |
10.72%
2.4 pts better
|
No Different than the National Rate · Eligible stays 346 · Observed rate 5.49% · Lower 95% interval 6.39% |
| Discharge to community | 63.63% |
50.57%
13.1 pts better
|
Better than the National Rate · Eligible stays 345 · Observed rate 60% · Lower 95% interval 58.47% |
| Medicare spending per beneficiary | 0.71 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 96.95% |
95.27%
1.7 pts better
|
Numerator 191 · Denominator 197 |
| Falls with major injury | 0.51% |
0.77%
0.3 pts better
|
Numerator 1 · Denominator 197 |
| Discharge self-care score | 27.85% |
53.69%
25.8 pts worse
|
Numerator 44 · Denominator 158 |
| Discharge mobility score | 41.14% |
50.94%
9.8 pts worse
|
Numerator 65 · Denominator 158 |
| Pressure ulcers or injuries, new or worsened | 1.52% |
2.29%
0.8 pts better
|
Numerator 3 · Denominator 197 · Adjusted rate 1.76% |
| Healthcare-associated infections requiring hospitalization | 5.29% |
7.12%
1.8 pts better
|
No Different than the National Rate · Eligible stays 201 · Observed rate 2.99% · Lower 95% interval 3.61% |
| Staff COVID-19 vaccination coverage | 18.75% |
8.2%
10.6 pts better
|
Numerator 30 · Denominator 160 |
| Staff flu vaccination coverage | 64.81% |
42%
22.8 pts better
|
Numerator 140 · Denominator 216 |
| Discharge function score | 37.34% |
56.45%
19.1 pts worse
|
Numerator 59 · Denominator 158 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 42 · Denominator 42 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 124 · Denominator 124 |
| Resident COVID-19 vaccinations up to date | 41.44% |
25.2%
16.2 pts better
|
Numerator 46 · Denominator 111 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
97.3%
2 pts better
|
93.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 97.1% · 4Q avg 99.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.1%
3.9 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 | 7.2% |
3.9%
3.3 pts worse
|
3.3%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 9.4% · Q3 9.1% · Q4 5.7% · 4Q avg 7.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.2% |
4.3%
1.1 pts better
|
11.4%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 3.7% · Q3 3.6% · Q4 3.1% · 4Q avg 3.2% |
| Percentage of long-stay residents who lose too much weight | 5.0% |
4.1%
0.9 pts worse
|
5.4%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 4.2% · Q3 0.0% · Q4 0.0% · 4Q avg 5.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.0% |
12.4%
7.4 pts better
|
19.6%
14.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 8.3% · Q3 4.3% · Q4 6.9% · 4Q avg 5.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.3% |
17.5%
8.2 pts better
|
16.7%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 9.5% · Q4 12.0% · 4Q avg 9.3% · 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 | 44.7% |
22.5%
22.2 pts worse
|
16.3%
28.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 44.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.2% |
18.6%
5.6 pts worse
|
14.9%
9.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 48.0% · Q2 20.8% · Q3 13.6% · Q4 14.3% · 4Q avg 24.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
2.3%
2.3 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.9% |
2.6%
0.3 pts worse
|
1.7%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 3.1% · Q3 0.0% · Q4 2.9% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 40.5% |
24.8%
15.7 pts worse
|
19.8%
20.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 53.9% · Q2 40.6% · Q3 38.8% · Q4 28.1% · 4Q avg 40.5% |
| Percentage of long-stay residents with pressure ulcers | 4.1% |
5.4%
1.3 pts better
|
5.1%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 3.9% · Q3 3.6% · Q4 6.1% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.4% |
88.6%
4.8 pts better
|
81.7%
11.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.4% · Q2 93.9% · Q3 92.9% · Q4 90.6% · 4Q avg 93.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.4% |
14.0%
0.6 pts better
|
12.0%
1.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.4% · Observed 12.0% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.9%
1 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.0% · Q3 0.5% · Q4 1.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.4% |
82.7%
8.7 pts better
|
79.7%
11.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.3% |
23.1%
3.2 pts worse
|
23.9%
2.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.3% · Observed 21.7% · Expected 19.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-11 · Fire 2024-04-11
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-08-31 · Fire 2023-08-31
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-05-22
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-06-09
E · Potential for more than minimal harm
2025-05-22
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-06-09
D · Potential for more than minimal harm
2025-05-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-06-09
F · Potential for more than minimal harm
2023-08-31
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2023-09-01
D · Potential for more than minimal harm
2023-08-31
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-08-29
D · Potential for more than minimal harm
2023-08-31
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-08-29
D · Potential for more than minimal harm
2023-08-31
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-08-29
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-05-09
F627 · Resident Rights Deficiencies
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-09
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-02-27
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-03-28
D · Potential for more than minimal harm
2023-08-31
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-09-22
Penalties and ownership
What sits behind the stars
Ownership
Covenant Living Communities & Services
5% Or Greater Direct Ownership Interest · Organization
Bentley, Sarah
Corporate Director · Individual
Christensen, Pamela
Corporate Director · Individual
Cunliffe, Terri
Corporate Officer · Individual
Cunliffe, Terri
W-2 Managing Employee · Individual
Davis, Kara
Corporate Director · Individual
Eastburg, Mark
Corporate Director · Individual
Erickson, David
Corporate Officer · Individual
Erickson, Rebekah
Corporate Officer · Individual
Holt, Jody
Operational/Managerial Control · Individual
Holt, Jody
Corporate Officer · Individual
Kincannon, Kurt
Corporate Director · Individual
Manlove, Matt
Corporate Director · Individual
Martin, Robert
Corporate Director · Individual
Nelson, Richard
Corporate Director · Individual
Oxendale, Roger
Corporate Director · Individual
Rinard, Dale
Corporate Director · Individual
Vanover, Andrew
Corporate Director · Individual
Wenrich, John
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Courage Kenny Rehabilitation Institutes Trp
Golden Valley, MN
5-star overall rating with 4-star inspections with 2 recent health deficiencies
#2
The Villas At Brookview
Golden Valley, MN
3-star overall rating with 3-star inspections with $26,685 in total fines with 10 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Good Samaritan Ambassador
New Hope, MN
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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