St Joseph, MI

Coventry House Inn

4-star overall rating with 3-star inspections with 8 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle

3905 Lorraine Path, St Joseph, MI

(269) 428-1111

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

5 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Symphony Care Network

Operator or chain grouping

Approved since

2003-03-14

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

7 facilities

Chain averages 2 overall / 2 health / 3 staffing / 4 quality stars

Changed ownership

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

1.78

Registered nurse staffing · state 0.77 · national 0.68

LPN hours / resident day

0.26

Licensed practical nurse staffing · state 0.88 · national 0.87

Aide hours / resident day

2.41

Nurse aide staffing · state 2.38 · national 2.35

Total nurse hours

4.46

All reported nurse hours · state 4.03 · national 3.89

Licensed hours

2.05

RN + LPN hours · state 1.65 · national 1.54

Weekend hours

4.04

Weekend nurse staffing · state 3.52 · national 3.43

Weekend RN hours

1.35

Weekend registered nurse coverage · state 0.49 · national 0.47

Physical therapist

0.16

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

1.89

CMS adjusted RN staffing hours

Adjusted total hours

4.72

CMS adjusted total nurse staffing hours

Case-mix index

1.29

Higher values indicate more complex resident acuity

RN turnover

29%

Annual RN turnover · state 41% · national 45%

Total nurse turnover

36%

Annual nurse turnover · state 44% · national 46%

SNF VBP

Value-based purchasing

Program rank

592

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

66.87

Composite VBP score used to determine payment impact.

Payment multiplier

1.0206

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

8.11

Baseline 16.37% · Performance 17.67% · Measure score 8.11 · Achievement 8.11 · Improvement 0

Healthcare-associated infections

6.61

Baseline 4.99% · Performance 5.86% · Measure score 6.61 · Achievement 6.61 · Improvement 0

Total nurse turnover

8.91

Baseline 55.81% · Performance 27.27% · Measure score 8.91 · Achievement 8.91 · Improvement 8.72

Adjusted total nurse staffing

3.12

Baseline 4.02 hours · Performance 3.96 hours · Measure score 3.12 · Achievement 3.12 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	8.84%	10.72% 1.9 pts better	No Different than the National Rate · Eligible stays 168 · Observed rate 5.36% · Lower 95% interval 6.57%
Discharge to community	52.69%	50.57% 2.1 pts better	No Different than the National Rate · Eligible stays 164 · Observed rate 50% · Lower 95% interval 44.9%
Medicare spending per beneficiary	1.21	1.02 0.2 pts worse
Drug regimen review with follow-up	95.93%	95.27% 0.7 pts better	Numerator 118 · Denominator 123
Falls with major injury	0.81%	0.77% About the same	Numerator 1 · Denominator 123
Discharge self-care score	58.95%	53.69% 5.3 pts better	Numerator 56 · Denominator 95
Discharge mobility score	47.37%	50.94% 3.6 pts worse	Numerator 45 · Denominator 95
Pressure ulcers or injuries, new or worsened	0.81%	2.29% 1.5 pts better	Numerator 1 · Denominator 123 · Adjusted rate 0.85%
Healthcare-associated infections requiring hospitalization	5.86%	7.12% 1.3 pts better	No Different than the National Rate · Eligible stays 104 · Observed rate 2.88% · Lower 95% interval 3.48%
Staff COVID-19 vaccination coverage	15.87%	8.2% 7.7 pts better	Numerator 10 · Denominator 63
Staff flu vaccination coverage	41.03%	42% 1 pts worse	Numerator 48 · Denominator 117
Discharge function score	57.89%	56.45% 1.4 pts better	Numerator 55 · Denominator 95
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 33 · Denominator 33
Transfer of health information to patient	98.77%	96.28% 2.5 pts better	Numerator 80 · Denominator 81
Resident COVID-19 vaccinations up to date	9.09%	25.2% 16.1 pts worse	Numerator 6 · Denominator 66

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	95.0% 5 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	6.1%	3.1% 3 pts worse	3.3% 2.8 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 6.1% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.0%	4.1% 4.1 pts better	11.4% 11.4 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0%
Percentage of long-stay residents who lose too much weight	6.2%	5.5% 0.7 pts worse	5.4% 0.8 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 6.2%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	6.1%	19.6% 13.5 pts better	19.6% 13.5 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 6.1%
Percentage of long-stay residents who received an antipsychotic medication	26.9%	16.5% 10.4 pts worse	16.7% 10.2 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 26.9% · 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 · 4Q avg 0.0%
Percentage of long-stay residents whose need for help with daily activities has increased	12.9%	11.7% 1.2 pts worse	14.9% 2 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 12.9% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.9% 0.9 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.0%	1.7% 1.7 pts better	1.7% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	10.3%	20.4% 10.1 pts better	19.8% 9.5 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 10.3%
Percentage of long-stay residents with pressure ulcers	0.0%	5.6% 5.6 pts better	5.1% 5.1 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	97.0%	82.8% 14.2 pts better	81.7% 15.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 93.4% · Q2 95.9% · Q3 98.7% · Q4 100.0% · 4Q avg 97.0%
Percentage of short-stay residents who had an outpatient emergency department visit	6.3%	11.5% 5.2 pts better	12.0% 5.7 pts better	Short Stay · 20240701-20250630 · Adjusted 6.3% · Observed 5.7% · Expected 10.1% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.5%	1.3% 0.8 pts better	1.6% 1.1 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.9% · Q4 0.9% · 4Q avg 0.5% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	89.8%	79.5% 10.3 pts better	79.7% 10.1 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 89.8%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	30.4%	24.2% 6.2 pts worse	23.9% 6.5 pts worse	Short Stay · 20240701-20250630 · Adjusted 30.4% · Observed 27.6% · Expected 21.6% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-12-05 · Fire 2024-12-05

8 health deficiencies

Top issue: Nutrition and Dietary (2 deficiencies)

6 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 2 Health 2023-11-02 · Fire 2023-11-02

13 health deficiencies

Top issue: Resident Rights (3 deficiencies)

4 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Cycle 3 Health 2022-10-20 · Fire 2022-10-20

9 health deficiencies

Top issue: Administration (2 deficiencies)

2 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-12-05

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2025-01-10

F · Potential for more than minimal harm 2024-12-05

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-01-10

F · Potential for more than minimal harm 2024-12-05

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-01-10

F · Potential for more than minimal harm 2024-12-05

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-01-10

E · Potential for more than minimal harm 2024-12-05

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2025-01-10

E · Potential for more than minimal harm 2024-12-05

K781 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of portable space heaters.

Corrected 2025-01-10

F · Potential for more than minimal harm 2023-11-02

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-12-04

F · Potential for more than minimal harm 2023-11-02

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2023-12-04

F · Potential for more than minimal harm 2023-11-02

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-12-04

E · Potential for more than minimal harm 2023-11-02

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2023-12-04

F · Potential for more than minimal harm 2023-05-16

K711 · Miscellaneous Deficiencies

Fire Safety

Provide a written emergency evacuation plan.

Corrected 2023-06-28

E · Potential for more than minimal harm 2023-05-16

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2023-06-28

Inspection history

Recent health citations

F · Potential for more than minimal harm 2024-12-05

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 2025-01-10

E · Potential for more than minimal harm 2024-12-05

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2025-01-10

D · Potential for more than minimal harm 2024-12-05

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2025-01-10

D · Potential for more than minimal harm 2024-12-05

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-01-10

D · Potential for more than minimal harm 2024-12-05

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 2025-01-10

D · Potential for more than minimal harm 2024-12-05

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2025-01-10

D · Potential for more than minimal harm 2024-12-05

F758 · Pharmacy Service Deficiencies

Health

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected 2025-01-10

D · Potential for more than minimal harm 2024-12-05

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-01-10

F · Potential for more than minimal harm 2023-11-02

F680 · Quality of Life and Care Deficiencies

Health

Ensure the activities program is directed by a qualified professional.

Corrected 2023-12-08

F · Potential for more than minimal harm 2023-11-02

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 2023-12-08

F · Potential for more than minimal harm 2023-11-02

F835 · Administration Deficiencies

Health

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Corrected 2023-12-08

E · Potential for more than minimal harm 2023-11-02

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 2023-12-08

E · Potential for more than minimal harm 2023-11-02

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-01-08

E · Potential for more than minimal harm 2023-11-02