Public Record
Covenant Shores Health Center
From CMS
Facility profile
- CMS overall rating
- 5 / 5
- Certified beds
- 43
- Avg. residents per day
- 38
*CMS Five-Star
*CMS
*CMS
Inspection record
On record from CMS
- Citations on record
- 97
- Inspections on file
- 8
- Last inspection
- 2026-02-11
*CMS
*CMS
*CMS
Citations
97 citations on record
Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0355Generalpotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
- 0712Generalpotential for harm
Have simulated fire drills held at unexpected times.
- 0741Generalpotential for harm
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- 0781Generalpotential for harm
Have restrictions on the use of portable space heaters.
- 0918Generalpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0761Generalpotential for harm
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.
- 0610Generalpotential for harm
Respond appropriately to all alleged violations.
- 0605Generalpotential for harm
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
- 0609Generalpotential for harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- 0645Generalpotential for harm
PASARR screening for Mental disorders or Intellectual Disabilities
- 0657Generalpotential for harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- 0658Generalpotential for harm
Ensure services provided by the nursing facility meet professional standards of quality.
- 0677Generalpotential for harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0020Generalpotential for harm
Establish policies and procedures including evacuation.
- 0100Generalpotential for harm
Meet other general requirements.
- 0222Generalpotential for harm
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.
- 0291Generalpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0324Generalpotential for harm
Provide properly protected cooking facilities.
- 0345Generalpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0351Generalpotential for harm
Install an approved automatic sprinkler system.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0711Generalpotential for harm
Provide a written emergency evacuation plan.
- 0921Generalpotential for harm
Ensure that testing and maintenance of electrical equipment is performed.
- 0552Generalpotential for harm
Ensure that residents are fully informed and understand their health status, care and treatments.
- 0015Generalpotential for harm
Address subsistence needs for staff and patients.
- 0024Generalpotential for harm
Establish policies and procedures for volunteers.
- 0223Generalpotential for harm
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
- 0321Generalpotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0324Generalpotential for harm
Provide properly protected cooking facilities.
- 0345Generalpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0355Generalpotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
- 0511Generalpotential for harm
Have properly installed electrical wiring and gas equipment.
- 0531Generalpotential for harm
Have elevators that firefighters can control in the event of a fire.
- 0541Generalpotential for harm
Install properly constructed and protected linen or trash chutes.
- 0623Generalpotential for harm
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
- 0645Generalpotential for harm
PASARR screening for Mental disorders or Intellectual Disabilities
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0761Generalpotential for harm
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.
- 0554Generalpotential for harm
Allow residents to self-administer drugs if determined clinically appropriate.
- 0578Generalpotential for harm
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
- 0610Generalpotential for harm
Respond appropriately to all alleged violations.
- 0923Generalpotential for harm
Have proper medical gas storage and administration areas.
- 0311Generalpotential for harm
Have an enclosure around a vertical opening shaft.
- 0641Generalpotential for harm
Ensure each resident receives an accurate assessment.
- 0645Generalpotential for harm
PASARR screening for Mental disorders or Intellectual Disabilities
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0657Generalpotential for harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- 0658Generalpotential for harm
Ensure services provided by the nursing facility meet professional standards of quality.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0686Generalpotential for harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- 0688Generalpotential for harm
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0697Generalpotential for harm
Provide safe, appropriate pain management for a resident who requires such services.
- 0758Generalpotential for harm
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.
- 0761Generalpotential for harm
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.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0030Generalpotential for harm
List the names and contact information of those in the facility.
- 0035Generalpotential for harm
Provide family notifications of emergency plan.
- 0100Generalpotential for harm
Meet other general requirements.
- 0225Generalpotential for harm
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
- 0291Generalpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0324Generalpotential for harm
Provide properly protected cooking facilities.
- 0341Generalpotential for harm
Install a fire alarm system that can be heard throughout the facility.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0363Generalpotential for harm
Install corridor and hallway doors that block smoke.
- 0511Generalpotential for harm
Have properly installed electrical wiring and gas equipment.
- 0521Generalpotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- 0712Generalpotential for harm
Have simulated fire drills held at unexpected times.
- 0918Generalpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0921Generalpotential for harm
Ensure that testing and maintenance of electrical equipment is performed.
- 0926Generalpotential for harm
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
- 0009Generalpotential for harm
Include a process for Emergency Preparedness collaboration.
- 0015Generalpotential for harm
Address subsistence needs for staff and patients.
- 0024Generalpotential for harm
Establish policies and procedures for volunteers.
- 0880Seriousimmediate jeopardy
Provide and implement an infection prevention and control program.
- 0835Generalpotential for harm
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0881Generalpotential for harm
Implement a program that monitors antibiotic use.
- 0886Generalpotential for harm
Perform COVID19 testing on residents and staff.
- 0761Generalpotential for harm
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.
- 0758Generalpotential for harm
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.
- 0700Generalpotential for harm
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
- 0578Generalpotential for harm
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
- 0607Generalpotential for harm
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
- 0690Generalpotential for harm
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- 0641Generalpotential for harm
Ensure each resident receives an accurate assessment.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0658Generalpotential for harm
Ensure services provided by the nursing facility meet professional standards of quality.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0825Generalpotential for harm
Provide or get specialized rehabilitative services as required for a resident.
Inspection history
Every health inspection on record
Each CMS health inspection of this facility, and the deficiencies the surveyors cited. Where the verbatim Form 2567 statement of deficiencies is on file, it links to the full report.
- View inspection reportInspection25 deficiencies
- View inspection reportInspection25 deficiencies
- View inspection reportInspection22 deficiencies
- View inspection reportInspection22 deficiencies
- View inspection reportInspection34 deficiencies
- View inspection reportInspection34 deficiencies
- View inspection reportInspection2 deficiencies
- View inspection reportInspection14 deficiencies
FAQ
Questions and answers
- What is Covenant Shores Health Center?
- Covenant Shores Health Center is a Medicare- and Medicaid-certified nursing home in Mercer Island, WA, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 505504.
- What is the CMS rating for Covenant Shores Health Center?
- Covenant Shores Health Center has a CMS overall rating of 5 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
- How many beds does Covenant Shores Health Center have?
- Covenant Shores Health Center is certified for 43 beds. It serves an average of 38 residents per day.
- How many citations does Covenant Shores Health Center have?
- Covenant Shores Health Center has 97 citations on record from CMS health inspections, each tied to a federal deficiency tag.
- When was Covenant Shores Health Center last inspected?
- Covenant Shores Health Center was last inspected on February 11, 2026. CMS surveys nursing homes about once a year and after complaints.
- What can I do if I have concerns about care at this facility?
- Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.
*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.
/nursing-home/505504-covenant-shores-health-center