Covenant Village of the Great Lakes

In the surveyor’s words

From the most serious findings on record at Covenant Village of the Great Lakes, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF880Mar 26, 2026

  Based on interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP), resulting in the potential for increased risk of respiratory infection among all residents in the facility.Findings include: On 3/24/26 at 1:14 PM, a review of the facility provided document entitled Legionella Policy, dated 12/21/2022, found that the the Water Management Program will be reviewed at least once a year . The document also states that, .our facility has a water management program, which is overseen by the water management team. […]

• No harm, potential for more than minimal, widespreadF882Mar 5, 2025

  Based on interview and record review, the facility failed to ensure the Infection Preventionist completed specialized training in infection prevention and control, resulting in the potential for knowledge deficits pertaining to current infection prevention and control standards and infectious disease outbreaks in a vulnerable population of 29 residents. Findings include: Findings include: During the entrance conference interview on 3/4/25 at 10:30 AM, Nursing Home Administrator (NHA) A stated, The (Director of Nursing (DON) B is the Infection Control Preventionist (ICP). During an interview on 3/4/25 at 2:20 PM, DON/ICP B stated, (Assistant Director of Nursing (ADON) C) is the Infection Control Preventionist. […]

• No harm, potential for more than minimal, widespreadF812Jan 11, 2023

  Based on observation, interview, and record review the facility failed to: 1. Properly date mark and discard food product; 2. Clean food and non-food contact surfaces to sight and touch. and 3; Properly cool potentially hazardous foods. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 32 residents who consume food from the kitchen. Findings include: 1. During the initial tour of the kitchen, at 9:02 AM on 1/9/23, with Sous Chef (SC) C, observation of the walk-in cooler found the following items not dated or held beyond their discard date: open container of beef base not dated, a container of Lobster soup base dated 11/6/22 to 12/6/22, a case of strawberry banana yogurt (2/3 full) with a use by date of 1/4/23. […]

• No harm, potential for more than minimal, widespreadF921Jan 11, 2023

  This citation pertains to intake #: MI00132189 Based on observation, interview, and record review, the facility failed to clean and maintain premises in a manner that would reduce the risk of contamination of clean and sanitary linens and maintain resident satisfaction of cleanliness. This deficient practice increases the likelihood of contamination and possible decrease in the satisfaction of living for all residents. Findings include: During a tour of the facility, starting at 1:42 PM on 1/10/23, with Maintenance J, it was observed that the following areas of the facility were found with an increased accumulation of dust, debris, and/or trash accumulation under open wire rack shelving: South hall linen room, South hall storage room, North hall linen room, North hall storage room, and the… […]

• No harm, potential for more than minimal, widespreadF882Oct 28, 2022

  Based on interview and record review, the facility failed to employ an Infection Preventionist with specialized training in infection prevention and control, resulting in the potential for knowledge deficit pertaining to current infection prevention and control standards and infectious disease outbreaks. Findings include: In an interview on 10/26/2022 at 08:40 AM, Executive Director C reported that the facility did not currently have an Infection Preventionist with specialized training. In an interview on 10/28/2022 at 10:32 AM, Facility Administrator A reported that the facility did not currently have a certified Infection Preventionist. […]