Inspection Reports for
Covenant Living of the Great Lakes
2510 Lake Michigan Dr NW, Grand Rapids, MI 49504, MI, 49504
Back to Facility Profile4 Reports
Inspection Report — Mar 30, 2026
Complaint Investigation
Date: Mar 30, 2026
Visit Reason
Investigation of a complaint received on 2026-03-25 about medication administration.
Complaint Details
Resident A did not receive prescribed blood pressure medication for 8 days: not established. Additional findings: Resident A did not receive prescribed multivitamin tablets as ordered — established.
Findings
One violation was established related to medication administration; the facility failed to ensure Resident A received prescribed multivitamin tablets as ordered. The allegation that Resident A did not receive blood pressure medication for 8 days was not established.
Deficiencies (1)
R 325.1932 Resident medications: Resident A did not receive the prescribed multivitamin tablets as ordered because the medication was not administered by the home despite the service plan indicating the home was responsible.
Report Facts
Corrective action plan due: 15
Inspection Report — Aug 12, 2025
Complaint Investigation
Date: Aug 12, 2025
Visit Reason
Investigation of a complaint received on 2025-08-11 about medication management, care provision, and call light response.
Complaint Details
Resident A fell due to medication stoppage: established. Staff did not provide care per service plan: established. Resident A’s call lights not answered timely: established. Additional findings: none.
Findings
Three rule violations were established related to medication supervision, care provision consistent with the service plan, and timely response to call lights.
Deficiencies (3)
R 325.1932 Resident medications: the facility did not act in a timely manner to ensure Resident A’s anti-seizure medication was refilled prior to exhaustion, contributing to Resident A’s fall with injury.
R 325.1931 Employees; general provisions: discrepancies and lack of documentation showed Resident A did not consistently receive care and assistance as required by the service plan.
R 325.1931 Employees; general provisions: multiple call light response times exceeded 20 minutes, indicating staff did not respond in a timely manner to Resident A’s call lights.
Report Facts
Corrective action plan due: 15
Inspection Report — Sep 12, 2024
Complaint Investigation
Date: Sep 12, 2024
Visit Reason
Investigation of a complaint received on 2024-09-10 about Resident A's care and living conditions.
Complaint Details
Resident A did not receive timely emergency care when Resident A demonstrated a change in condition: not established. Resident A’s room smelled of urine and multiple soiled briefs were found in the bathroom: not established. Resident A was not provided a shower for three weeks in August in 2024: established. Resident A did not receive fresh meals from 8/15/2024 to 8/17/2024 and a meal tray was left in Resident A’s room for two days: not established.
Findings
One rule violation was established regarding personal care; three other allegations were not substantiated.
Deficiencies (1)
R 325.1933 Personal care of residents: due to discrepancies in documentation and staff interviews, it could not be determined if Resident A received showers consistent with the service plan, resulting in a violation.
Report Facts
Corrective action plan due: 15
Inspection Report — Apr 23, 2024
Renewal
Date: Apr 23, 2024
Visit Reason
Renewal inspection of the adult foster care family home license.
Findings
The facility was found to be in substantial compliance with the public health code and administrative rules regulating home for the aged facilities.
4 CMS Surveys
Inspection Report — Mar 5, 2025
Complaint Investigation
Date: Mar 5, 2025
Visit Reason
Investigation of a complaint received on 2025-03-05 about resident care, medication administration, adaptive dining equipment, medical records, infection control, and vaccination policies.
Complaint Details
Failure to provide showers per resident preference: established. Medication administration without physician approval: established. Adaptive dining equipment not consistently provided: established. Inaccurate advance directive documentation: established. Infection prevention and control deficiencies including PPE use and training: established. Pneumococcal vaccination policy outdated: established.
Findings
Five deficiencies were established related to failure to provide showers per resident preference, failure to follow physician medication orders, failure to provide adaptive dining equipment consistently, failure to maintain accurate medical records for advance directives, and failure to implement proper infection prevention and control practices including PPE use and infection preventionist training. Additionally, the facility's pneumococcal vaccination policy was outdated and did not reflect current CDC guidance.
Deficiencies (7)
F 0561 Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice: Resident #17 did not receive showers as frequently as scheduled due to miscommunication between facility and hospice staff, resulting in only 8 showers out of 25 opportunities over 12.5 weeks.
F 0658 Ensure services provided by the nursing facility meet professional standards of quality: Licensed Practical Nurse administered a stock medication without documented physician approval, contrary to the physician order for Resident #9.
F 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance: Resident #179 was not consistently provided dual handled cups for all beverages as recommended by occupational therapy, resulting in difficulty drinking and risk of dehydration.
F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards: Resident #17 had conflicting documentation regarding advance directives with a DNR order in the chart but a Full Code physician order.
F 0880 Provide and implement an infection prevention and control program: Facility failed to ensure appropriate PPE use during foley catheter care for residents #5 and #16, had inadequate signage and stocked isolation carts, and lacked clear training and communication for hospice and agency staff on Enhanced Barrier Precautions.
F 0882 Designate a qualified infection preventionist to be responsible for the infection prevention and control program in the nursing home: The designated Infection Preventionist had not completed specialized infection control training or certification at the time of the survey.
F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations: The facility's pneumococcal vaccine policy was outdated and did not include current CDC recommendations for PCV15 and PCV20 vaccines.
Inspection Report — Jan 26, 2024
Complaint Investigation
Date: Jan 26, 2024
Visit Reason
Investigation of a complaint received on 2024-01-26 about failure to document resident grievances.
Complaint Details
Failure to document resident grievances: established.
Findings
The facility failed to document resident concerns as grievances according to facility policy, resulting in a potential decline in resident well-being.
Deficiencies (1)
F 0585 Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. The facility failed to document Resident #182's concerns as a grievance despite knowledge of the issue.
Inspection Report — Jan 26, 2024
Complaint Investigation
Date: Jan 26, 2024
Visit Reason
Investigation of complaints received on various topics including resident dignity, care planning, activities of daily living, pressure ulcer care, transfer safety, respiratory care, medication storage, and medical records accuracy.
Complaint Details
Resident dignity issues: established. Death tracking assessment missing: established. PASARR Level II screening not completed: established. Incomplete care plans for insulin and prafo boot: established. Inadequate activities of daily living care: established. Pressure ulcer prevention failures: established. Gait belt not used during transfers: established. CPAP mask cleaning not performed daily: established. Medication labeling and expired medication issues: established. Missing vaccine consent documentation: established.
Findings
Multiple deficiencies were found including failure to promote resident dignity, incomplete care plans, inadequate activities of daily living assistance, insufficient pressure ulcer prevention, unsafe transfer practices without gait belt use, improper respiratory equipment cleaning, medication storage issues, and incomplete medical records.
Deficiencies (10)
F 0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights: aides failed to provide timely assistance and used personal cell phones in resident rooms, causing residents to feel disrespected and humiliated.
F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment: facility failed to complete and transmit a death tracking assessment for a resident who expired in the facility.
F 0645 PASARR screening for Mental disorders or Intellectual Disabilities: facility failed to ensure a Level II OBRA evaluation screening was completed for a resident who remained beyond 30 days after an exempted hospital stay.
F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured: care plans for insulin use and prafo boot care were missing for two residents.
F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable: a dependent resident was observed with unremoved facial hair, long soiled fingernails, and wet clothing due to incontinence, with staff failing to provide timely care.
F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing: facility failed to provide adequate bed mobility and incontinence care for a resident at high risk for skin breakdown, resulting in wet clothing and potential for pressure ulcers.
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: facility failed to use gait belts during resident transfers, increasing risk of injury.
F 0695 Provide safe and appropriate respiratory care for a resident when needed: facility failed to clean a resident's CPAP mask daily as required, increasing risk of respiratory infection.
F 0761 Ensure 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: insulin was not dated when opened and expired medication was not removed from stock.
F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards: facility failed to maintain signed vaccine consent documentation for a resident despite vaccine administration.
Inspection Report — Jan 11, 2023
Monitoring
Date: Jan 11, 2023
Visit Reason
Interim inspection to determine compliance.
Findings
Multiple deficiencies were found related to resident care, medication storage, food service, activities, and safety, resulting in potential harm or dissatisfaction for residents.
Deficiencies (12)
F 0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights: the facility failed to provide timely care and services to promote dignity in 2 residents, resulting in long call light wait times, episodes of incontinence, and feelings of embarrassment and frustration.
F 0558 Reasonably accommodate the needs and preferences of each resident: the facility failed to ensure access to a call light in 1 resident, resulting in inability to call for assistance and potential unmet care needs.
F 0561 Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice: the facility failed to ensure showers/daily dental care was provided/offered per resident preference and plan of care in 3 residents, resulting in potential dissatisfaction, hygiene concerns, skin irritation, and low self-esteem.
F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered: the facility failed to provide Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) forms to 2 residents, resulting in potential unawareness of financial liability changes.
F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured: the facility failed to develop or implement comprehensive care plans for 2 residents, one with a catheter and one receiving anticoagulant medication, resulting in potential unmet medical care needs.
F 0679 Provide activities to meet all resident's needs: the facility failed to provide meaningful activities based on comprehensive assessment for 1 resident with severe cognitive impairment, resulting in potential decline in physical, mental, and psychosocial well-being.
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to utilize wheelchair footrests for safe wheelchair transport for 1 resident, resulting in potential for falls, injury, and unmet care needs.
F 0761 Ensure 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: the facility failed to securely store medications in 1 medication cart, resulting in potential for misappropriation and unauthorized access.
F 0803 Ensure 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: the facility failed to obtain and/or honor food preferences for 4 residents, resulting in dissatisfaction, frustration, and potential inadequate intake and weight loss.
F 0809 Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests: the facility failed to serve resident meals in a timely manner and per scheduled times for 2 residents and 3 residents in a confidential group, resulting in delayed meal service and potential dissatisfaction.
F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: the facility failed to properly date mark and discard food products, clean food and non-food contact surfaces, and properly cool potentially hazardous foods, resulting in increased risk of contaminated foods and foodborne illness affecting 32 residents.
F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards: the facility failed to maintain an accurate medical record and complete a Falls Risk Assessment for 1 resident following multiple falls, resulting in potential for additional falls due to lack of assessment and intervention.
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