Covenant Village of the Great Lakes
Open-data reference.
Covenant Village of the Great Lakes is a non profit - corporation facility in Grand Rapids, MI with 37 certified beds and a 4-star overall CMS rating. The facility has 30 deficiency records on file.
2520 Lake Michigan Drive NW, Grand Rapids, MI 49504
Phone: 6167356050
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 235614
- Ownership
- Non profit - Corporation
- Provider Type
- Medicare and Medicaid
- Beds
- 37
- Residents
- 29
- In Hospital
- No
- County
- Kent
- Last Inspection
- Mar 5, 2025
Staffing Data
- RN Hours
- 1.01 (nat'l avg: 0.68)
- LPN Hours
- 1.02
- CNA Hours
- 2.54
- Total Nursing Hours
- 4.57 (nat'l avg: 3.89)
- PT Hours
- 0.09
- Nursing Turnover
- 45.0%
- RN Turnover
- 42.9%
What the CMS Record Reveals About Covenant Village of the Great Lakes
Covenant Village of the Great Lakes operates 37 certified beds in Grand Rapids, MI with approximately 29 residents currently in care, and carries a CMS overall rating of 4 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (4★), staffing levels (4★), and quality measures (4★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 30 deficiency records from recent surveys, all falling in the no-harm or minimal-harm bands of the CMS scope-and-severity grid. No fines or payment denials have been assessed against this provider, suggesting issues — if any — did not rise to the enforcement threshold. Staffing is reported at 4.57 total nursing hours per resident day (national average 3.89), with RN coverage at 1.01 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "Non profit - Corporation" ownership and operating as a "Medicare and Medicaid" provider, Covenant Village of the Great Lakes falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 45.0%, within a range generally associated with stable care teams. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (30 most recent)
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category: Infection Control Deficiencies
Corrected: Apr 4, 2025
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Category: Infection Control Deficiencies
Corrected: Mar 28, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Apr 5, 2025
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Mar 28, 2025
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Category: Nutrition and Dietary Deficiencies
Corrected: Mar 28, 2025
Ensure services provided by the nursing facility meet professional standards of quality.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Mar 28, 2025
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Category: Resident Rights Deficiencies
Corrected: Mar 28, 2025
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.
Category: Resident Rights Deficiencies
Corrected: Feb 14, 2024
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Feb 14, 2024
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.
Category: Pharmacy Service Deficiencies
Corrected: Feb 14, 2024
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Feb 14, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Feb 14, 2024
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Feb 14, 2024
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Feb 14, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Feb 14, 2024
PASARR screening for Mental disorders or Intellectual Disabilities
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Feb 14, 2024
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Feb 14, 2024
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category: Resident Rights Deficiencies
Corrected: Feb 14, 2024
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Feb 3, 2023
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Feb 3, 2023
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Category: Nutrition and Dietary Deficiencies
Corrected: Feb 3, 2023
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.
Category: Nutrition and Dietary Deficiencies
Corrected: Feb 3, 2023
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.
Category: Pharmacy Service Deficiencies
Corrected: Feb 3, 2023
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Feb 3, 2023
Provide activities to meet all resident's needs.
Category: Quality of Life and Care Deficiencies
Corrected: Feb 3, 2023
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Feb 3, 2023
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Category: Resident Rights Deficiencies
Corrected: Feb 3, 2023
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Category: Resident Rights Deficiencies
Corrected: Feb 3, 2023
Reasonably accommodate the needs and preferences of each resident.
Category: Resident Rights Deficiencies
Corrected: Feb 3, 2023
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category: Resident Rights Deficiencies
Corrected: Feb 3, 2023
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 19.0% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 1.8% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.8% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 2.8% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 6.1% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 2.7% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 97.3% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 90.8% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.8% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | N/A | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 1.7% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 95.2% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 85.9% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 16.4% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 22.6% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 7.7% | Yes |
Penalty History
No penalties on record.
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County Health Data
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Frequently Asked Questions
What is the overall CMS rating for Covenant Village of the Great Lakes?
What are the staffing levels at Covenant Village of the Great Lakes?
How many beds does Covenant Village of the Great Lakes have?
Does Covenant Village of the Great Lakes have any deficiencies on record?
Has Covenant Village of the Great Lakes received any fines or penalties?
Who owns Covenant Village of the Great Lakes?
When was Covenant Village of the Great Lakes last inspected?
What quality measures are tracked for Covenant Village of the Great Lakes?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.