Above average — CMS composite of the measures below.
The next survey window likely opens around February 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 Village Of The Great Lakes during CMS and state inspections, most recent first.
Infection Prevention and Water Management Program Deficiency: The facility failed to maintain an active and ongoing Legionella/OPPP control program. The Legionella Policy required annual review and a water management team with key facility leaders, but the Water Management Program contained former employees, later listed only two members, and lacked documentation of free chlorine residual testing from the domestic water supply used by residents. The MS stated the vendor collected samples and had the updated documents, while the facility provided only cooling tower chlorine residual work orders.
A resident with emphysema, chronic respiratory failure, and O2 dependence was observed using O2 by nasal cannula and appeared short of breath. Although the physician ordered O2 at 2L/min at rest and 4L with activity, the baseline care plan only noted that the resident received oxygen and did not include interventions or specific instructions. Staff interviews confirmed CNAs relied on the care summary for guidance, but the resident’s respiratory needs were not fully documented there, and the care plan lacked respiratory interventions.
A resident with depression, anxiety, and a history of COVID had a UTI treated with antibiotics and was placed on contact precautions for ESBL in urine. Although the resident later came off isolation and no precaution signs were posted outside or inside the room, the care plan still showed active contact isolation and active infection in urine. The ADON/IP stated the resident was no longer under contact precautions and that those care plans should have been deleted or resolved.
Failure to Prevent Pressure Ulcers and Protect Existing Wounds: Two residents were affected by inadequate pressure injury prevention and wound protection. One resident with impaired mobility and moderate cognitive impairment developed a new stage 3 pressure ulcer on the buttock after spending long periods in a wheelchair, with staff describing turning in bed, a wheelchair cushion, and encouragement to lie down but no clear offloading plan while seated. Another resident was admitted with multiple pressure injuries, including heel wounds, yet heel protectors were observed unused in the room, the heels rested directly on the mattress, and the baseline care plan lacked specific wound interventions.
The facility failed to ensure the designated Infection Preventionist (ICP) completed specialized training in infection prevention and control. The DON, identified as the ICP, admitted to not being certified and only recently starting the required course. Confusion about the ICP's identity and the inability to provide the ICP's certificate upon request indicate non-compliance with infection control standards, potentially affecting 29 residents.
The facility did not update its pneumococcal vaccine policy to include current CDC recommendations for PCV15 and PCV20, potentially leaving residents at risk. The DON was unaware of these vaccines and the facility failed to provide an updated policy before the survey exit.
A resident, who was cognitively impaired and required assistance with bathing, reported receiving only one shower per week instead of the scheduled two. The facility's staff mistakenly believed hospice staff was responsible for both showers, leading to the resident's dissatisfaction and potential hygiene issues. The Assistant Director of Nursing acknowledged the error, and the Nursing Home Administrator was unable to provide additional documentation to verify the resident's shower schedule.
A facility did not follow professional standards for physician orders when an LPN administered a different dosage of iron medication to a resident with iron deficiency anemia without documented physician approval. The LPN acknowledged the lack of authorization but stated that nurses had been substituting the medication based on an assumed general approval from the facility's doctor, contrary to the facility's policy.
A resident with muscle weakness and dysphagia was not consistently provided with adaptive dining equipment, specifically two-handled cups, as recommended by occupational therapy. Despite the resident's expressed difficulty and preference for dual-handled cups, observations showed that beverages were often served in inappropriate containers, such as foam cups without handles. Facility staff confirmed the resident's need for adaptive equipment, but it was not consistently provided, contrary to facility policy.
A facility failed to maintain consistent documentation for a resident's Advance Directives and Code Status. The resident's paper-based chart and EMR indicated a DNR status, while a current physician order showed a Full Code status. This discrepancy was confirmed by an LPN and the ADON, who stated that all documentation should match to ensure clarity of the resident's care wishes.
The facility failed to ensure proper infection control practices during care for two residents, leading to potential disease spread. One resident with multiple diagnoses was on Enhanced Barrier Precautions (EBP), but necessary PPE was unavailable. Another resident with a foley catheter received care from an aide not wearing a gown, despite EBP signage. The DON/ICP was unsure of PPE requirements, and isolation carts were not stocked. The ADON noted training was conducted, but there was no formal documentation for agency and hospice staff.
Infection Prevention and Water Management Program Deficiency
Penalty
Summary
Provide and implement an infection prevention and control program was deficient because the facility did not have an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing. A review of the facility’s Legionella Policy dated 12/21/2022 found that the Water Management Program was to be reviewed at least once a year and that the facility had a water management program overseen by the water management team. However, the Water Management Program dated September 2020 listed multiple team members who were former employees of the facility. The Water Management Program identified control measure DWM06 as monitoring disinfectant level in the water supply and distal faucets. During interview, the Maintenance Supervisor stated the control limits were completed as they came up in the maintenance system, but the vendor took the samples and had the updated documents. After additional email follow-up, the facility stated it would be educating staff and reinstituting free chlorine monitoring. A later document titled Water Management Plan dated March 24, 2026 listed only two team members, one vendor contact and one facility staff member, despite the Legionella Policy stating the water management team should include the Facilities Maintenance Co-Lead, Infection Preventionist Co-Lead, Healthcare Administrator, DON, and Medical Director or designee. The facility also provided work orders for maintaining chlorine residual in the cooling towers, but no documentation showing tests for free chlorine residual from the domestic water supply used by residents.
Failure to Include Oxygen Needs in Baseline Care Plan
Penalty
Summary
The facility failed to develop a person-centered baseline care plan for Resident #46 within 48 hours of admission. Resident #46 was a female admitted with diagnoses including centrilobular emphysema, chronic respiratory failure, and dependence on oxygen. She was observed sitting in bed with a nasal cannula in place and an oxygen concentrator running at 2L, and she appeared short of breath. During interviews, she stated she always wore oxygen, including in the shower, and that without oxygen she became very winded and could not do anything until she caught her breath. The physician order sheet showed oxygen at 2 L/min by nasal cannula, with 2L continued at rest, 4L with activity, and titration to 1L. The nursing admission respiratory evaluation documented labored rhythm and oxygen therapy. The resident care touchscreen summary listed oxygen use and noted oxygen at 4L for activity and 2L at rest, but the baseline care plan only stated that the resident receives oxygen and contained no interventions. The comprehensive care plan also listed respiratory status with a goal that the resident would be free of respiratory distress, but it had no interventions. Staff interviews confirmed the omission. The CNA stated she relied on the resident care summary for specific care instructions and did not have access to physician orders. The RN stated oxygen use was not part of the baseline care plan and that CNAs would need specific oxygen information because they exchange portable oxygen tanks and need the liter flow set. The CRM/RN stated respiratory status and oxygen use should be placed directly on the resident care summary, but Resident #46’s summary did not include specifics, and her respiratory care plan had no interventions listed. The DON stated the baseline care plan should be created within 48 hours and include basic information about how to care for the resident, including physician orders, and the ADON confirmed there were no interventions related to oxygen use.
Failure to Update Care Plan After UTI Isolation Ended
Penalty
Summary
The facility failed to revise Resident #7’s person-centered care plan to reflect current care needs after the resident’s urinary tract infection and contact precautions had ended. Resident #7 was admitted with diagnoses including depression, anxiety, and history of COVID, and the BIMS score was 13 out of 15, indicating the resident was cognitively intact. Review of the record showed that on 2/24/2026 the nurse practitioner evaluated the resident’s culture and sensitivity, discontinued the previous antibiotic, started nitrofurantoin for treatment of a UTI, and contact precautions were initiated. Progress notes on 2/28/2026 and 3/1/2026 documented that the resident continued on antibiotics and remained on isolation, with the note on 3/1/2026 stating contact isolation would continue until the next day. During observation on 3/24/2026, there were no contact precaution signs or enhanced barrier precaution signs outside or inside the resident’s room. The care plan still listed active problems for isolation/contact isolation due to ESBL in urine and active infection in urine, with interventions for transmission-based precautions and PPE. The ADON/IP stated the resident was no longer under contact precautions because the infection had resolved and said the contact isolation and active infection care plans should have been deleted or resolved. The MDS nurse stated she initiated nursing care plans and that updates were also helped with by the ADON/IP and DON, and the administrator was informed that the infection care plans had not been updated.
Failure to Prevent Pressure Ulcers and Protect Existing Wounds
Penalty
Summary
The facility failed to prevent the development and worsening of pressure ulcers for two residents. One resident was a female with diagnoses including gait and mobility abnormalities, difficulty walking, lack of coordination, and an existing stage 3 pressure area on the left buttock. Her MDS showed moderate cognitive impairment and substantial to maximal assistance was required for rolling and sit-to-stand. A wound care note documented a new pressure wound on the left buttock, and staff stated the resident spent much of the day sitting in her wheelchair and sometimes refused to lie down. Staff also reported that the resident was encouraged to reposition and had a wheelchair cushion, but there was no documentation of a specific method to offload pressure while she remained seated in the wheelchair. Interviews with nursing staff, CNAs, and the DON showed that prior to the wound, prevention focused on turning in bed, incontinence care, barrier cream, and a wheelchair cushion. Staff repeatedly stated the resident liked to stay in her chair and sometimes refused to lie down, but they did not describe an effective offloading intervention for when she remained seated for extended periods. Several staff members stated there was nowhere to document turning and repositioning, and the NHA reported the system was not set up to document refusals unless an order was in place. The resident’s care plan addressed skin risk, incontinence, mobility, nutrition, heel protection, and an APM mattress, but it did not document that she preferred to stay in her wheelchair or include adequate interventions for prolonged sitting. The second resident was admitted with multiple pressure injuries, including wounds to both elbows, the left buttock, coccyx, and bilateral heels. On observation, the resident was lying supine in bed while heel protectors were seen in a reclining chair rather than on the resident’s feet, and her heels were resting directly on the mattress. Wound care documentation described bilateral heel deep tissue injuries with purple discoloration, and nursing admission documentation noted the heels were intact but mushy. The baseline care plan listed wound care but did not include specific interventions for the pressure injuries, and staff gave conflicting accounts about whether heel boots were being used. The wound care orders for the heels and encouragement to use heel offloading boots were not entered until after the heels were observed with purple blister-like areas.
Infection Preventionist Lacks Required Certification
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (ICP) completed specialized training in infection prevention and control. During an entrance conference, the Nursing Home Administrator (NHA) identified the Director of Nursing (DON) as the ICP. However, subsequent interviews revealed confusion about the ICP's identity, with the Assistant Director of Nursing (ADON) also being mentioned as involved in infection control. The DON, who was confirmed as the ICP, admitted to not being certified in infection control and only recently starting the required course. The facility was unable to provide the ICP's infection control certificate upon request, indicating a lack of compliance with infection prevention and control standards, potentially affecting 29 residents.
Failure to Update Pneumococcal Vaccine Policy
Penalty
Summary
The facility failed to develop and implement policies and procedures that align with current standards of practice regarding pneumococcal immunizations. Specifically, the facility's policy on pneumococcal vaccines, last revised in March 2022, did not include recommendations for the PCV15 and PCV20 vaccines as per the latest CDC guidance. This oversight resulted in the potential for eligible residents not being offered these vaccines, thereby increasing their risk of acquiring, transmitting, or experiencing complications from pneumococcal pneumonia. During an interview, the Director of Nursing (DON) admitted to being unaware of the types of pneumococcal vaccines available for residents and the CDC's recommendations concerning PCV15 and PCV20 immunizations. The facility did not provide an updated policy or procedure reflecting the current guidance before the survey exit. The CDC's recommendations, dated October 24, 2024, advise routine administration of PCV15 or PCV20 for all adults of a certain age who have never received any pneumococcal conjugate vaccine or whose vaccination history is unknown. The lack of updated policies and procedures in the facility reflects a significant gap in ensuring residents receive appropriate immunizations.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to provide showers according to the resident's preference, resulting in dissatisfaction with care and potential hygiene issues. Resident #17, who was cognitively impaired and required substantial assistance with bathing, reported receiving only one shower per week instead of the scheduled two. The resident's shower schedule indicated she was to receive showers twice a week, but a review of shower sheets revealed she only received 8 out of 25 scheduled showers over a period of 12.5 weeks. The Assistant Director of Nursing (ADON) acknowledged the issue, explaining that facility staff mistakenly believed hospice staff was responsible for both scheduled showers, leading to the resident receiving only one shower per week. The Nursing Home Administrator (NHA) was unable to provide additional documentation to verify the resident's shower schedule, as the wrong report was initially submitted. This lack of coordination and documentation resulted in the resident not receiving the care as per her preference.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to adhere to professional standards of practice regarding physician orders for a resident diagnosed with iron deficiency anemia. The physician's order specified the administration of Slow Fe 137 mg (45 mg iron) tablet, extended release, to be given once daily. However, during medication administration, an LPN provided a different dosage of Fe 325 mg (65 mg essential iron) without documented approval from the physician to interchange with a stock medication. The LPN acknowledged the absence of a physician's note authorizing the substitution but stated that nurses had been administering the stock medication based on a general understanding that the facility's doctor permitted it. This practice was not supported by the facility's policy, which requires a current list of orders to be maintained in the clinical record of each resident.
Inconsistent Provision of Adaptive Dining Equipment
Penalty
Summary
The facility failed to consistently provide adaptive dining equipment for a resident, identified as Resident #179, who required such equipment due to medical conditions including muscle weakness, osteoarthritis, and dysphagia. The resident was cognitively intact and had been evaluated by occupational therapy, which recommended the use of a two-handled cup for all beverages to aid in safe and efficient eating. Despite this recommendation, observations revealed that the resident was frequently provided with beverages in inappropriate containers, such as disposable foam cups without handles and regular mugs with one handle, which the resident found difficult to manage. During multiple observations, Resident #179 expressed difficulty and concern with using the provided cups, stating that cups without two handles could easily slip from her hands, leading to potential spills. The resident reported that she preferred the dual-handled cups, which were easier to use, and expressed worry about dropping drinks. Despite the resident's needs and preferences, the facility staff, including dietary aides and certified nurse aides, did not consistently provide the recommended adaptive equipment, as evidenced by the presence of non-compliant cups during meal times. Interviews with facility staff, including a dietary aide, dietary manager, and director of therapy, confirmed that the resident was supposed to receive all beverages in dual-handled cups. The dietary manager acknowledged that the dual-handled cups could accommodate both hot and cold liquids, and the director of therapy confirmed the occupational therapy recommendation for dual-handled cups. The facility's policy on assistance with meals also stated that adaptive devices should be provided for residents who need or request them, yet this was not consistently followed for Resident #179.
Inconsistent Advance Directives Documentation
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident regarding Advance Directives and Code Status. The resident's paper-based medical chart and Electronic Medical Record (EMR) both indicated a Do Not Resuscitate (DNR) status. However, a current physician order for the resident indicated a Full Code status, creating a discrepancy in the resident's medical records. This inconsistency was confirmed during an interview with a Licensed Practical Nurse (LPN) and the Assistant Director of Nursing (ADON), who acknowledged that all documentation related to a resident's advance directives should be consistent to ensure clarity of the resident's care wishes.
Inadequate Infection Control Practices During Resident Care
Penalty
Summary
The facility failed to ensure proper infection control practices were followed during foley catheter care and brief changes for two residents, resulting in a potential risk for disease spread. One resident had multiple diagnoses, including chronic multifocal osteomyelitis and pressure ulcers, and was on Enhanced Barrier Precautions (EBP). However, during an observation, the necessary personal protective equipment (PPE) such as eye coverings was not available, and the signage did not clearly indicate the required PPE. Another resident, who had a foley catheter, was observed receiving care from a hospice aide who was not wearing a gown, despite the presence of EBP signage. The aide was unaware of the precautions and did not change gloves between tasks, which is against the facility's policy. The Director of Nursing/Infection Control Preventionist (DON/ICP) was also unsure of the specific PPE requirements for EBP and noted that the isolation carts were not properly stocked. The Assistant Director of Nursing (ADON) mentioned that the facility had conducted staff training on infection control, but there was no formal documentation of training for agency and hospice staff. The facility's policy on EBP, which follows CDC guidelines, requires specific PPE during high-contact activities, but there was a lack of clarity and communication regarding these requirements among staff, leading to the observed deficiencies.
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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 Grand Rapids
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Ann's Home | 1.1 mi | ★★★★★ | 6 | 0 |
| Edison Christian Health Center | 1.1 mi | ★★★★★ | 16 | 0 |
| Valley View Care Center | 2.2 mi | ★★★★★ | 13 | 2 |
| Mary Free Bed Sub-acute Rehabilitation | 3.5 mi | ★★★★★ | 2 | 0 |
| Michigan Veteran Homes At Grand Rapids | 4.5 mi | ★★★★★ | 0 | 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 July 2026) and official state health department websites.