Cycle 1
Health 2025-03-05 · Fire 2025-03-05
7 health deficiencies
Top issue: Infection Control (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Grand Rapids, MI
Covenant Village of the Great Lakes
4-star overall rating with 4-star inspections with 7 recent health deficiencies
2520 Lake Michigan Drive NW, Grand Rapids, MI
(616) 735-6050
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
37
Certified beds
Average residents
29
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Covenant Living
Operator or chain grouping
Approved since
2004-10-28
CMS approved date
Coverage
Medicare + Medicaid
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
1.01
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.02
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.54
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
4.57
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
2.03
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
4.09
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.65
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.94
CMS adjusted RN staffing hours
Adjusted total hours
4.28
CMS adjusted total nurse staffing hours
Case-mix index
1.46
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,256
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.26
Composite VBP score used to determine payment impact.
Payment multiplier
0.9859
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.50
Baseline 19.84% · Performance 20.74% · Measure score 1.50 · Achievement 1.50 · Improvement 0
Healthcare-associated infections
3.50
Baseline 5.35% · Performance 6.79% · Measure score 3.50 · Achievement 3.50 · Improvement 0
Total nurse turnover
4.06
Baseline 69.05% · Performance 48.89% · Measure score 4.06 · Achievement 3.62 · Improvement 4.06
Adjusted total nurse staffing
3.04
Baseline 3.97 hours · Performance 3.94 hours · Measure score 3.04 · Achievement 3.04 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.04% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 89 · Observed rate 7.87% · Lower 95% interval 7.29% |
| Discharge to community | 65.55% |
50.57%
15 pts better
|
Better than the National Rate · Eligible stays 86 · Observed rate 61.63% · Lower 95% interval 55.33% |
| Medicare spending per beneficiary | 0.79 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 92.5% |
95.27%
2.8 pts worse
|
Numerator 37 · Denominator 40 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 40 |
| Discharge self-care score | 41.67% |
53.69%
12 pts worse
|
Numerator 15 · Denominator 36 |
| Discharge mobility score | 33.33% |
50.94%
17.6 pts worse
|
Numerator 12 · Denominator 36 |
| Pressure ulcers or injuries, new or worsened | 5% |
2.29%
2.7 pts worse
|
Numerator 2 · Denominator 40 · Adjusted rate 4.84% |
| Healthcare-associated infections requiring hospitalization | 6.79% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 42 · Observed rate 4.76% · Lower 95% interval 3.35% |
| Staff COVID-19 vaccination coverage | 1.02% |
8.2%
7.2 pts worse
|
Numerator 1 · Denominator 98 |
| Staff flu vaccination coverage | 16.46% |
42%
25.5 pts worse
|
Numerator 13 · Denominator 79 |
| Discharge function score | 47.22% |
56.45%
9.2 pts worse
|
Numerator 17 · Denominator 36 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 31 · Denominator 31 |
| Resident COVID-19 vaccinations up to date | 31.82% |
25.2%
6.6 pts better
|
Numerator 7 · Denominator 22 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.3% |
95.0%
2.3 pts better
|
93.4%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · 4Q avg 97.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.2% |
95.0%
0.2 pts better
|
95.5%
0.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.7% |
3.1%
0.4 pts better
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.1% |
4.1%
2 pts worse
|
11.4%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · 4Q avg 6.1% |
| Percentage of long-stay residents who lose too much weight | 1.8% |
5.5%
3.7 pts better
|
5.4%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 1.7% |
19.6%
17.9 pts better
|
19.6%
17.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.7% |
16.5%
8.8 pts better
|
16.7%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.7% · 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% · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.0% |
11.7%
7.3 pts worse
|
14.9%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 19.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
0.9%
0.1 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.8% |
1.7%
1.1 pts worse
|
1.7%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.6% |
20.4%
2.2 pts worse
|
19.8%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.6% |
| Percentage of long-stay residents with pressure ulcers | 16.4% |
5.6%
10.8 pts worse
|
5.1%
11.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.5% · 4Q avg 16.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.8% |
82.8%
8 pts better
|
81.7%
9.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.1% · Q2 82.3% · Q3 85.2% · Q4 98.4% · 4Q avg 90.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.5% |
11.5%
8 pts worse
|
12.0%
7.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.5% · Observed 16.2% · Expected 9.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.3%
0.5 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.5% · Q4 1.7% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.9% |
79.5%
6.4 pts better
|
79.7%
6.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.0% |
24.2%
11.2 pts better
|
23.9%
10.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 13.0% · Observed 10.8% · Expected 19.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-26 · Fire 2024-01-26
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2023-01-11 · Fire 2023-01-11
13 health deficiencies
Top issue: Resident Rights (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-01-26
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-02-21
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-03-05
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2025-03-28
E · Potential for more than minimal harm
2025-03-05
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-03-05
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-03-28
D · Potential for more than minimal harm
2025-03-05
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-03-28
D · Potential for more than minimal harm
2025-03-05
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2025-03-28
D · Potential for more than minimal harm
2025-03-05
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 2025-03-28
D · Potential for more than minimal harm
2025-03-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-05
D · Potential for more than minimal harm
2024-01-26
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-02-14
D · Potential for more than minimal harm
2024-01-26
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2024-02-14
D · Potential for more than minimal harm
2024-01-26
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-02-14
D · Potential for more than minimal harm
2024-01-26
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-02-14
D · Potential for more than minimal harm
2024-01-26
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-02-14
D · Potential for more than minimal harm
2024-01-26
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-02-14
D · Potential for more than minimal harm
2024-01-26
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-02-14
D · Potential for more than minimal harm
2024-01-26
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-02-14
D · Potential for more than minimal harm
2024-01-26
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-02-14
D · Potential for more than minimal harm
2024-01-26
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-02-14
D · Potential for more than minimal harm
2024-01-26
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 2024-02-14
F · Potential for more than minimal harm
2023-01-11
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-02-03
E · Potential for more than minimal harm
2023-01-11
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-02-03
E · Potential for more than minimal harm
2023-01-11
F803 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2023-02-03
E · Potential for more than minimal harm
2023-01-11
F809 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2023-02-03
D · Potential for more than minimal harm
2023-01-11
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-02-03
D · Potential for more than minimal harm
2023-01-11
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-02-03
D · Potential for more than minimal harm
2023-01-11
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-02-03
D · Potential for more than minimal harm
2023-01-11
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-02-03
D · Potential for more than minimal harm
2023-01-11
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-02-03
D · Potential for more than minimal harm
2023-01-11
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-02-03
D · Potential for more than minimal harm
2023-01-11
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 2023-02-03
C · Minimal harm
2023-01-11
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-02-03
Penalties and ownership
What sits behind the stars
Ownership
Covenant Living Communities & Services
5% Or Greater Direct Ownership Interest · Organization
Aagaard, Jon
Operational/Managerial Control · Individual
Christensen, Pamela
Contracted Managing Employee · Individual
Cunliffe, Terri
Corporate Officer · Individual
Cunliffe, Terri
W-2 Managing Employee · Individual
Eastburg, Mark
Operational/Managerial Control · Individual
Erickson, David
Corporate Officer · Individual
Espinosa, Marc
Operational/Managerial Control · Individual
Hodgkinson, Donald
Operational/Managerial Control · Individual
Holt, Jody
Corporate Officer · Individual
Manlove, Matt
Corporate Director · Individual
Oxendale, Roger
Corporate Director · Individual
Stante, Marlene
Operational/Managerial Control · Individual
Vining, Anne
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
St Ann's Home
Grand Rapids, MI
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Edison Christian Health Center
Grand Rapids, MI
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Valley View Care Center
Grand Rapids, MI
1-star overall rating with 1-star inspections with abuse icon flag with $43,876 in total fines with 15 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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