Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Coventry House Inn during CMS and state inspections, most recent first.
The facility failed to maintain food safety and sanitation standards, with dirty non-food contact surfaces and unlabeled, undated cooked foods. The dish machine's temperature was not monitored due to a damaged gauge, and internal food temperatures were not checked before serving. Opened food items in the nourishment room lacked labeling, increasing the risk of foodborne illness.
The facility failed to serve food at a palatable temperature, affecting two residents and several others from a resident meeting. A cognitively intact male and female resident reported food not being consistently hot enough. During a meal service observation, food temperatures were below expected levels, and a CNA confirmed resident complaints about food temperature.
A resident with diabetes mellitus received medication without a physician's order due to a failure in following professional standards of practice. The resident was prescribed Insulin Lispro, but a nurse administered Novolog insulin, mistakenly believing it to be the same. The DON was unaware of the presence of two types of insulin in the medication cart, and there was no order for Novolog.
A resident with stasis dermatitis experienced burning pain and potential exacerbation of their condition due to the facility's failure to coordinate care according to physician orders. The care plan lacked specific interventions for dry skin, and the resident's legs were wrapped with ace bandages that were not changed regularly. Staff interviews revealed inconsistencies in care, with no documentation of the resident's skin condition being monitored and inappropriate orders for as-needed application of wraps.
A resident on antiplatelet medication experienced multiple falls, including head trauma, but was not sent to the hospital for evaluation, contrary to standard care practices. The facility's policy relied on monitoring for neurological changes, but the Medical Director noted that such changes might go unnoticed, highlighting a deficiency in care standards.
A facility failed to ensure a physician reviewed a pharmacist's medication regimen recommendations for a resident with anxiety disorder. The pharmacist recommended reviewing the need for Hydroxyzine, a psychotropic medication prescribed PRN, as per regulatory guidelines. The process to address these recommendations was not followed, leading to a delay in the physician's review and signature, potentially causing negative medication side effects.
The facility failed to discontinue PRN psychotropic medications for two residents after 14 days or document the rationale for continued use, as required by regulations. A resident with generalized anxiety disorder was prescribed Hydroxyzine without a stop date, and another resident with unspecified anxiety disorder was prescribed Klonopin under similar circumstances. The lack of a 14-day stop date or documented justification for continued use was confirmed by the Social Services Director.
A facility failed to follow infection control standards during blood sugar assessments for three residents. An RN used the same glucometer without cleaning it between uses and did not perform hand hygiene after glove removal, contrary to facility policy. The DON confirmed the expectation for glucometer disinfection between residents.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain proper food safety and sanitation standards, as observed during a kitchen/food service tour. Non-food contact surfaces, such as the floor of the walk-in cooler and the vent above the meat freezer, were found to be dirty and dusty. Additionally, cooked potentially hazardous food products, including roast beef and Spanish rice, were not labeled or dated with a prepared and discard date. The facility also did not maintain a cooling log for these foods, which is necessary to ensure proper time/temperature cooling as per the 2017 FDA Food Code. The dish machine was found to have a water-damaged temperature gauge, and there were no temperature entries recorded for December 2024, indicating that the machine's temperature was not being monitored to ensure proper sanitization. Furthermore, the internal temperatures of cooked foods were not checked before serving, as evidenced by the lack of documented food temperatures since September 2024. In the nourishment room, several opened food items were not labeled with an opened or discard date, increasing the risk of foodborne illness for residents consuming food from the kitchen.
Failure to Serve Food at Palatable Temperature
Penalty
Summary
The facility failed to ensure that food products were served at a palatable temperature, affecting two of twelve sampled residents and five of six residents from a confidential resident meeting. Resident #22, a cognitively intact male, expressed concerns about the food not being consistently hot enough, even when dining in the dining room. Similarly, Resident #133, a cognitively intact female, reported that the food was consistently not hot enough. During a confidential resident meeting, one resident mentioned having to send meals back due to hot foods being served cold, and five out of six residents reported that the lunch served was barely warm. Observations during a tray line/meal service revealed that food temperatures were below the expected levels, with meatballs and gravy at 128 degrees, buttered noodles at 126 degrees, and spinach at 128 degrees. The food was plated and covered but placed on a non-heated portion of the steam table before being delivered to residents. A CNA confirmed that residents had complained about the food not being hot enough when served. These findings indicate a failure in maintaining food at a palatable temperature, leading to dissatisfaction and potential nutritional decline among residents.
Medication Administration Error for Diabetic Resident
Penalty
Summary
The facility failed to adhere to professional standards of practice for medication administration for a resident with diabetes mellitus, resulting in the administration of medication without a physician's order. The resident, who had been managing her Type 1 diabetes with insulin for many years, expressed concerns about the facility's understanding of her condition. The physician's orders specified the use of Insulin Lispro via a pen-injector according to a sliding scale before meals and at bedtime. However, during a medication administration observation, a registered nurse prepared and administered 5 units of Insulin Lispro to the resident. On a subsequent day, another registered nurse prepared and administered 3 units of Novolog insulin using a syringe, mistakenly believing it to be the same as Insulin Lispro. The nurse acknowledged that the resident had both types of insulin available and intended to notify the doctor to obtain an order for Novolog. The Director of Nursing was unaware of the presence of two different types of fast-acting insulin in the medication cart and confirmed that there was no order for Novolog insulin. It was suggested that the Novolog vial might have been the resident's personal medication, inadvertently placed in the cart.
Deficiency in Coordination of Care for Resident with Stasis Dermatitis
Penalty
Summary
The facility failed to ensure proper coordination of care for a resident with skin conditions, specifically stasis dermatitis, resulting in burning pain and potential exacerbation of the condition. The resident's care plan included monitoring for signs of infection but lacked specific interventions for dry skin or the lower legs. Observations revealed that the resident's legs were wrapped with ace bandages, which were not changed regularly, and the application of lotion caused burning pain. The resident reported that the facility did not change the wraps regularly, and the lotion application was painful. Interviews with staff revealed inconsistencies in the care provided. A registered nurse reported that there were orders to apply Ammonium Lactate lotion twice daily, but the lotion was documented as refused or not administered in several instances. The director of nursing admitted to not knowing who applied the wraps or how long they had been in place, and there was no documentation of the resident's skin condition being monitored. The physician was not informed of the resident's legs being open and draining until questioned by the surveyor, and there was no order for the legs to be wrapped as needed for fluid drainage. The resident's initial admission from the hospital included an order for Ammonium Lactate cream to be applied as needed for dry skin. However, the facility did not have a clear plan for scheduled dressing changes or regular monitoring of the skin condition. The lack of documentation and assessment of the resident's skin condition, along with the inappropriate orders for as-needed application of wraps, contributed to the deficiency in care.
Failure to Send Resident on Antiplatelet Medication to Hospital After Falls
Penalty
Summary
The facility failed to maintain professional standards of care for a resident who was taking an antiplatelet medication, which increases the risk of bleeding, by not sending them to the hospital after sustaining head trauma from multiple falls. The resident, who had a history of coronary artery disease, experienced several falls, including an unwitnessed fall in the hallway and another fall next to their bed. Despite these incidents, the resident was not sent to the hospital for evaluation, which is the standard of care for individuals on antiplatelet medication who experience head trauma. The Director of Nursing reported that the facility's policy was to monitor for neurological abnormalities post-fall, and the decision to send the resident to the hospital was based on these assessments. However, the Medical Director indicated that the standard of care for residents on antiplatelet medication who experience head trauma is to send them to the hospital for evaluation, as minor neurological changes may go unnoticed by facility staff. The failure to adhere to this standard of care resulted in the potential for unidentified internal bleeding, which could lead to serious complications.
Failure to Address Pharmacist's Medication Review Recommendations
Penalty
Summary
The facility failed to ensure that a physician reviewed and responded to a registered pharmacist's monthly medication regimen review recommendations for a resident diagnosed with generalized anxiety disorder. The pharmacist's clinical record review, dated 11/7/24, included a recommendation regarding the resident's use of the psychotropic medication Hydroxyzine, which was prescribed on a PRN basis. According to regulatory guidelines, PRN orders for psychotropic medications must be limited to 14 days, and a new order requires a direct examination by the attending physician. The pharmacist recommended considering the continued need for the medication and documenting any benefits experienced by the resident. The deficiency occurred because the process for addressing pharmacist medication review reports was not followed. The report was supposed to be sent via electronic mail to the DON, MDS Nurse, and the doctor, then printed and placed in the doctor book for review. However, the report for the resident was not located in a timely manner, and the physician did not review or sign it until 12/5/24, nearly a month later. This delay resulted in the pharmacist's recommendations not being addressed promptly, potentially leading to negative medication side effects for the resident.
Failure to Discontinue PRN Psychotropic Medications
Penalty
Summary
The facility failed to adhere to regulatory guidelines regarding the use of PRN psychotropic medications, resulting in potential unnecessary medication use for two residents. Resident #2, diagnosed with generalized anxiety disorder, was prescribed Hydroxyzine 10 mg to be taken as needed for anxiety. However, the medication order did not include a 14-day stop date, which is required to prompt a review of the medication's effectiveness and continued need. A pharmacist's clinical record review highlighted this oversight, emphasizing the necessity for a direct examination by the attending physician to determine the medication's continued necessity. Similarly, Resident #134, with a diagnosis of unspecified anxiety disorder, was prescribed Klonopin 0.5 mg to be taken as needed for anxiety. This order also lacked a 14-day stop date or documented rationale for continued use beyond this period. The Social Services Director confirmed that both residents' PRN psychotropic medication orders should have been discontinued after 14 days or should have included documented justification for their continued use, as per regulatory requirements.
Infection Control Deficiency in Glucometer Use and Hand Hygiene
Penalty
Summary
The facility failed to adhere to infection control standards for hand hygiene and glucometer cleaning, as observed during blood sugar assessments for three residents. Registered Nurse (RN) J was seen performing blood sugar checks without cleaning the glucometer between uses and without performing hand hygiene after removing gloves. Specifically, RN J used the same glucometer for multiple residents without disinfecting it between uses, and did not perform hand hygiene after glove removal, which is against the facility's policy. During the observations, RN J was noted to have placed the uncleaned glucometer on the medication cart without a barrier sheet and proceeded to handle other items, such as a computer and insulin vial, without sanitizing his hands. The Director of Nursing confirmed that the expectation was for nurses to disinfect the glucometer between residents, which was not followed in these instances. The facility's policy on blood glucose monitoring machine cleaning, reviewed in May 2021, clearly outlines the need for cleansing and disinfecting the meter between each use and performing hand hygiene after glove removal.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 124 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near St Joseph
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Royalton Manor, Llc | 0.3 mi | — | 5 | 0 |
| Corewell Health Rehabilitation & Nursing Center - | 2.5 mi | — | 7 | 1 |
| West Woods Of Bridgman | 9.6 mi | — | 7 | 1 |
| The Orchards At Niles | 17.1 mi | — | 1 | 0 |
| The Timbers Of Cass County | 18.5 mi | — | 19 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Coventry House Inn.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.