01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2026-03-26 | 4 | 2026-03-26 | 1 |
| Cycle 2 | 2025-03-05 | 7 | 2025-03-05 | 0 |
| Cycle 3 | 2024-01-26 | 11 | 2024-01-26 | 1 |
CMS CCN 2356142026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Covenant Village Of The Great Lakes
2520 Lake Michigan Drive Nw · Grand Rapids, MI 49504 · Kent County
Certified beds37CMS provider file
Recent citation rows24current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
24 rows in the current release
0 rows carry G–L scope/severity codes; 0 carry J–L. 4 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-03-26 · FIREE0039Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Conduct testing and exercise requirements.
Correction field: Deficient, Provider has date of correction · 2026-04-172026-03-26 · HEALTHF0655Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Correction field: Deficient, Provider has date of correction · 2026-04-172026-03-26 · HEALTHF0657Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Correction field: Deficient, Provider has date of correction · 2026-04-172026-03-26 · HEALTHF0686Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2026-04-172026-03-26 · HEALTHF0880Severity F · widespread; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2026-04-172025-03-05 · HEALTHF0561Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Correction field: Deficient, Provider has date of correction · 2025-03-282025-03-05 · HEALTHF0658Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Correction field: Deficient, Provider has date of correction · 2025-03-282025-03-05 · HEALTHF0810Severity D · isolated; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Correction field: Deficient, Provider has date of correction · 2025-03-282025-03-05 · HEALTHF0842Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Correction field: Deficient, Provider has date of correction · 2025-03-282025-03-05 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-04-052025-03-05 · HEALTHF0882Severity F · widespread; potential for more than minimal harm
Infection Control Deficiencies
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Correction field: Deficient, Provider has date of correction · 2025-03-282025-03-05 · HEALTHF0883Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Correction field: Deficient, Provider has date of correction · 2025-04-042024-01-26 · FIREE0039Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Conduct testing and exercise requirements.
Correction field: Deficient, Provider has date of correction · 2024-02-212024-01-26 · HEALTHF0550Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Deficient, Provider has date of correction · 2024-02-142024-01-26 · HEALTHF0585Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-02-14 · complaint2024-01-26 · HEALTHF0640Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Correction field: Deficient, Provider has date of correction · 2024-02-142024-01-26 · HEALTHF0645Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
PASARR screening for Mental disorders or Intellectual Disabilities
Correction field: Deficient, Provider has date of correction · 2024-02-142024-01-26 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2024-02-142024-01-26 · HEALTHF0677Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Correction field: Deficient, Provider has date of correction · 2024-02-142024-01-26 · HEALTHF0686Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2024-02-142024-01-26 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2024-02-142024-01-26 · HEALTHF0695Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2024-02-142024-01-26 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-02-142024-01-26 · HEALTHF0842Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Correction field: Deficient, Provider has date of correction · 2024-02-1403 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- COVENANT LIVING COMMUNITIES & SERVICESOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 03/28/1995
- CHRISTENSEN, PAMELAIndividual · CONTRACTED MANAGING EMPLOYEENOT APPLICABLE · since 07/01/2013
- CUNLIFFE, TERRIIndividual · W-2 MANAGING EMPLOYEENOT APPLICABLE · since 05/22/2015
- MANLOVE, MATTIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2017
- OXENDALE, ROGERIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2017
- CUNLIFFE, TERRIIndividual · CORPORATE OFFICERNOT APPLICABLE · since 05/22/2015
- ERICKSON, DAVIDIndividual · CORPORATE OFFICERNOT APPLICABLE · since 01/31/2008
- HOLT, JODYIndividual · CORPORATE OFFICERNOT APPLICABLE · since 06/02/2017
- AAGAARD, JONIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/01/2013
- EASTBURG, MARKIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/01/2013
- ESPINOSA, MARCIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/01/2013
- HODGKINSON, DONALDIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/01/2013
- STANTE, MARLENEIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/01/2013
- VINING, ANNEIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/01/2013
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours4.28per resident day
RN hours0.94per resident day
Weekend nurse hours3.81per resident day
Staff turnover50.0%CMS reported field
06 / LOCAL RECORDS
Open the Grand Rapids ledger →Other published facilities nearby
Clark Retirement Community39 beds · CMS overall 2/537 citation rowsCorewell Health Grand Rapids Hospitals Rehabilitat120 beds · CMS overall 5/529 citation rowsCorewell Health Rehabilitation & Nursing Center -165 beds · CMS overall 5/531 citation rowsCorewell Health Rehabilitation & Nursing Center -80 beds · CMS overall 5/54 citation rowsEdison Christian Health Center136 beds · CMS overall 5/523 citation rowsHolland Home - Raybrook Manor101 beds · CMS overall 5/540 citation rowsHolland Home Breton Rehabilitation & Living Centre58 beds · CMS overall 5/515 citation rowsMary Free Bed Sub-Acute Rehabilitation48 beds · CMS overall 4/514 citation rows