Inspection Reports for
Covenant Living of the Great Lakes
2510 Lake Michigan Dr NW, Grand Rapids, MI 49504, MI, 49504
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
11.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
117% worse than Michigan average
Michigan average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Capacity: 102
Deficiencies: 3
Date: Aug 12, 2025
Visit Reason
The investigation was initiated due to a complaint alleging that Resident A fell and incurred multiple fractures due to abrupt stopping of anti-seizure medication by facility staff, failure to provide care in accordance with Resident A's service plan, and untimely response to Resident A's call lights.
Complaint Details
The complaint alleged that Resident A fell and incurred multiple fractures due to abrupt stopping of anti-seizure medication by facility staff, staff did not provide care according to Resident A's service plan, and Resident A's call lights were not answered timely. All allegations were substantiated with violations established.
Findings
The investigation established violations including failure to timely refill Resident A's anti-seizure medication which may have contributed to a fall with injury, discrepancies and lack of documentation regarding care provided per the service plan, and multiple instances of call light response times exceeding 20 minutes, indicating untimely staff response.
Deficiencies (3)
Failure to ensure Resident A's anti-seizure medication was refilled timely, resulting in medication interruption and contributing to a fall with injury.
Failure to provide care in accordance with Resident A's service plan, including inadequate documentation and discrepancies in care tasks such as showers and assistance with dressing and toileting.
Failure to respond to Resident A's call lights in a timely manner, with multiple response times exceeding 20 minutes and up to 99.3 minutes.
Report Facts
Capacity: 102
Call light uses: 30
Call light response time (minutes): 21.8
Call light response time (minutes): 41.9
Call light response time (minutes): 61.3
Call light response time (minutes): 58.4
Call light response time (minutes): 99.3
Call light response time (minutes): 34.5
Call light response time (minutes): 20.2
Showers documented: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julie Viviano | Licensing Staff | Author of the Special Investigation Report |
| Andrea Smith | Authorized Representative/Administrator | Facility representative interviewed during investigation |
| Employee 1 | Interviewed staff providing statements about Resident A's care and medication | |
| Employee 2 | Interviewed staff providing statements and documentation about Resident A's care and medication |
Inspection Report
Routine
Deficiencies: 7
Date: Mar 5, 2025
Visit Reason
Routine inspection of Covenant Village of the Great Lakes nursing home to assess compliance with regulatory standards including resident care, medication administration, infection control, and vaccination policies.
Findings
The facility had multiple deficiencies including failure to provide showers per resident preference, failure to follow physician medication orders, inconsistent provision of adaptive dining equipment, incomplete and inaccurate medical records regarding advance directives, inadequate infection control practices, lack of certified infection preventionist training, and outdated pneumococcal vaccination policies.
Deficiencies (7)
F 0561: The facility failed to provide showers per resident preference for Resident #17, resulting in dissatisfaction and potential for poor hygiene and infection.
F 0658: The facility failed to ensure professional standards for physician medication orders were followed for Resident #9, resulting in potential delay in treatment.
F 0810: The facility failed to provide adaptive dining equipment consistently for Resident #179, causing difficulty drinking and potential dehydration.
F 0842: The facility failed to maintain complete and accurate medical records related to advance directives for Resident #17, risking care wishes not being honored.
F 0880: The facility failed to ensure appropriate PPE was worn during foley catheter care for Residents #5 and #16, risking spread of infection.
F 0882: The facility failed to ensure the Infection Preventionist completed specialized training, risking knowledge deficits in infection control for 29 residents.
F 0883: The facility failed to update pneumococcal vaccination policies to include current CDC recommendations for PCV15 and PCV20 vaccines, risking residents not receiving appropriate immunizations.
Report Facts
Shower opportunities: 25
Residents reviewed for medication orders: 8
Residents reviewed for nutrition: 2
Residents reviewed for infection control: 12
Residents affected by infection preventionist training deficiency: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing C | Assistant Director of Nursing | Reported issues with Resident #17's shower schedule and infection control training. |
| Licensed Practical Nurse R | Licensed Practical Nurse | Observed medication administration issue for Resident #9. |
| Director of Nursing B | Director of Nursing/Infection Control Preventionist | Identified as Infection Control Preventionist, not yet certified, unaware of updated pneumococcal vaccine guidance. |
| Nursing Home Administrator A | Nursing Home Administrator | Provided information about shower documentation and infection control roles. |
| Dietary Manager H | Dietary Manager | Confirmed use of dual handled cups for Resident #179. |
| Director of Therapy J | Director of Therapy | Confirmed occupational therapy recommendations for Resident #179's adaptive dining equipment. |
Inspection Report
Complaint Investigation
Capacity: 102
Deficiencies: 1
Date: Sep 23, 2024
Visit Reason
The investigation was initiated due to a complaint alleging Resident A did not receive timely emergency care, experienced poor room conditions, was not provided showers for three weeks, and did not receive fresh meals for two days in August 2024.
Complaint Details
The complaint alleged Resident A did not receive timely emergency care, had a room smelling of urine with soiled briefs, was not provided showers for three weeks, and did not receive fresh meals from 8/15/2024 to 8/17/2024 with a meal tray left in the room for two days. Only the shower allegation was substantiated.
Findings
The investigation found that Resident A was not provided showers consistent with the service plan, resulting in a violation. Other allegations including lack of timely emergency care, poor room conditions, and failure to provide fresh meals were not substantiated. Facility staff were re-educated on protocols related to care and meal delivery.
Deficiencies (1)
Resident A was not provided showers consistent with the service plan for three weeks in August 2024.
Report Facts
Capacity: 102
Complaint Receipt Date: Sep 10, 2024
Investigation Initiation Date: Sep 12, 2024
Report Date: Sep 23, 2024
Violation Established: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Smith | Authorized Representative/Administrator | Interviewed regarding Resident A's care and facility protocols |
| Julie Viviano | Licensing Staff | Author of the inspection report |
Inspection Report
Renewal
Census: 29
Capacity: 102
Deficiencies: 0
Date: Apr 23, 2024
Visit Reason
The inspection was conducted as a renewal inspection to determine compliance with applicable licensing statutes and rules for the facility's license renewal.
Findings
The facility was found to be in substantial compliance with the public health code and administrative rules regulating home for the aged facilities. Renewal of the license is recommended contingent upon receipt of the annual renewal fee.
Report Facts
Number of staff interviewed and/or observed: 16
Number of residents interviewed and/or observed: 29
Capacity: 102
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 26, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to document resident grievances properly.
Complaint Details
This citation is related to intake #MI00135955. The complaint was substantiated as the facility failed to document the grievance of Resident #182 regarding unsanitary conditions and denial of shower.
Findings
The facility failed to document resident concerns according to its grievance policy for one resident, resulting in potential harm to residents' well-being. The grievance related to a resident being forced to use a dirty toilet and denied a shower was not documented as required.
Deficiencies (1)
F 0585: The facility failed to document resident grievances properly, specifically for Resident #182, resulting in potential harm. The resident's concerns about a dirty toilet and denied shower were not recorded as a grievance.
Report Facts
Residents reviewed for grievance resolution: 13
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker EE | Social Worker | Reported communication of resident concerns to Nursing Home Administrator and Director of Nursing |
| NHA A | Nursing Home Administrator | Reviewed resident progress notes and acknowledged failure to document grievance |
Inspection Report
Annual Inspection
Deficiencies: 10
Date: Jan 26, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including resident dignity, care planning, activities of daily living assistance, pressure ulcer prevention, transfer safety, respiratory care, medication management, and medical record accuracy. Deficiencies were generally of minimal harm with few residents affected.
Deficiencies (10)
F 0550: The facility failed to honor residents' dignity for 2 residents by not responding appropriately to requests and using personal cell phones during care.
F 0640: The facility failed to complete and transmit a death tracking assessment for 1 resident who expired in the facility.
F 0645: The facility failed to ensure a required Level II PASARR screening for 1 resident who remained beyond 30 days after hospital discharge.
F 0656: The facility failed to develop and implement complete person-centered care plans for 2 residents, lacking specific plans for insulin use and orthotic device care.
F 0677: The facility failed to provide adequate activities of daily living care including incontinence care, facial hair removal, and nail care for 1 dependent resident.
F 0686: The facility failed to provide appropriate pressure ulcer care and prevent skin breakdown for 1 resident dependent on staff for bed mobility and incontinence care.
F 0689: The facility failed to use a gait belt during transfers for 1 resident, increasing risk of injury.
F 0695: The facility failed to clean a CPAP mask according to policy for 1 resident, increasing risk of respiratory infection.
F 0761: The facility failed to date opened insulin and remove expired medication, risking decreased medication efficacy.
F 0842: The facility failed to maintain accurate medical records by lacking signed vaccine consent for 1 resident.
Report Facts
Residents reviewed: 15
Residents reviewed: 13
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing J | Assistant Director of Nursing | Reported staff were not allowed to use personal cell phones and discussed CPAP mask cleaning and insulin dating |
| Certified Nursing Assistant P | Certified Nursing Assistant | Reported turning off call light and leaving resident unattended |
| Licensed Practical Nurse T | Licensed Practical Nurse | Reported staff were not allowed to use personal cell phones |
| Minimum Data Set Coordinator F | Registered Nurse | Reported responsibility for MDS assessments and care planning |
| Social Worker EE | Social Worker | Reported failure to submit Level II PASARR screening paperwork |
| Certified Nurse Assistant O | Certified Nurse Assistant | Reported resident care needs and failure to provide care during shift |
| Licensed Practical Nurse M | Licensed Practical Nurse | Observed resident condition and reported on nail care responsibility |
| Director of Nursing B | Director of Nursing | Reported expectations for care, gait belt use, and vaccine consent documentation |
| Certified Nurse Assistant Q | Certified Nurse Assistant | Observed transfer without gait belt and reported transfer procedures |
| Certified Nurse Assistant K | Certified Nurse Assistant | Observed transfer without gait belt |
Inspection Report
Renewal
Deficiencies: 0
Date: Apr 28, 2023
Visit Reason
The document serves as a renewal notification for the Home for the Aged license following an administrative review of licensing activity for the past year.
Findings
The review revealed substantial compliance with the public health code and administrative rules regulating home for the aged facilities, resulting in the renewal of the facility's license.
Report Facts
License duration: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lauren Wohlfert | Licensing Staff | Signed the renewal notification letter |
Inspection Report
Routine
Deficiencies: 12
Date: Jan 11, 2023
Visit Reason
Routine inspection of Covenant Village of the Great Lakes nursing home to assess compliance with regulatory requirements related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to provide timely care and respect for residents' dignity, inadequate call light accessibility, incomplete care plans, insufficient activities for cognitively impaired residents, unsafe wheelchair transport, unsecured medication storage, inconsistent meal service and honoring food preferences, improper food storage and sanitation, and incomplete fall risk assessments.
Deficiencies (12)
F0550: The facility failed to provide timely care and services to promote dignity in 2 residents, resulting in long call light wait times and episodes of incontinence causing embarrassment and frustration.
F0558: 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.
F0561: The facility failed to ensure showers and daily dental care were provided per resident preference and plan of care in 3 residents, resulting in dissatisfaction, hygiene concerns, and low self-esteem.
F0582: The facility failed to provide Skilled Nursing Facility Advanced Beneficiary Notices to 2 residents, resulting in potential unawareness of financial liability changes.
F0656: The facility failed to develop and implement comprehensive care plans for 2 residents, missing care plans for catheter care and anticoagulant medication.
F0679: The facility failed to provide meaningful activities based on comprehensive assessment for 1 resident with severe cognitive impairment, resulting in potential decline in well-being.
F0689: The facility failed to utilize wheelchair footrests for safe transport for 1 resident, resulting in potential for falls and injury.
F0761: The facility failed to securely store medications in locked compartments in 1 medication cart, risking misappropriation and unauthorized access.
F0803: The facility failed to honor food preferences for 4 residents, resulting in dissatisfaction and potential inadequate intake and weight loss.
F0809: The facility failed to serve meals in a timely manner per schedule for 2 residents and 3 residents in a confidential council, resulting in delayed meals and dissatisfaction.
F0812: The facility failed to properly date mark and discard food, clean food and non-food contact surfaces, and properly cool potentially hazardous foods, increasing risk of foodborne illness affecting 32 residents.
F0842: The facility failed to maintain accurate medical records and complete fall risk assessments for 1 resident following multiple falls, risking additional falls due to lack of assessment and intervention.
Report Facts
Residents reviewed for meal services: 13
Residents affected by food preference deficiency: 4
Residents affected by call light deficiency: 1
Residents affected by dignity care deficiency: 2
Residents affected by shower/dental care deficiency: 3
Residents affected by SNF ABN deficiency: 2
Residents affected by care plan deficiency: 2
Residents affected by activities deficiency: 1
Residents affected by wheelchair safety deficiency: 1
Residents affected by medication storage deficiency: 1
Residents affected by meal timing deficiency: 2
Residents affected by food safety deficiency: 32
Residents affected by fall risk assessment deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| B | Director of Nursing | Reported staff responsibility for call light response and wheelchair safety |
| GG | Minimum Data Set Registered Nurse | Reported missing care plans and activity assessments |
| Q | Assistant Director of Nursing | Acknowledged unlocked medication cart |
| DD | Regional Registered Dietician | Confirmed multiple meal orders and kitchen ran out of menu option |
| D | Dining Room Manager | Described meal ordering process |
| C | Sous Chef | Reported meal timing issues and food safety concerns |
| T | Social Worker | Reported lack of SNF ABN forms and no facility policy |
| A | Nursing Home Administrator | Reported missing fall risk assessments |
Viewing
Loading inspection reports...
