Federal inspection record · CMS data as of October 1, 2026
Covenant Shores Health Center
9107 Fortuna Drive, Mercer Island, WA · (206) 316-8042
- CMS high-performer trophy
- Certified beds
- 43
- Residents per day
- 38
- Ownership
- Non-Profit
- Chain
- Covenant Living
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- September 4, 1997
1
How this home got 5 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Washington.
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Staffing
★★★★★+1 star
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★no change (already 5)
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★5 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Washington homes
Covenant Shores Health Center carries 52 inspection points. That is fewer than 76% of Washington's 192 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Washington: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–31 pts
- 4★ 31–69 pts
- 3★ 69–100 pts
- 2★ 100–167 pts
- 1★ over 167 pts
Bars show every rated home in Washington by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
35 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
No citation on record at the harm or immediate-jeopardy level.
Everything else, by area of care
Quality of Life and Care10E
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
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.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide safe and appropriate respiratory care for a resident when needed.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Resident Assessment and Care Planning10E
- D
PASARR screening for Mental disorders or Intellectual Disabilities
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
- E
PASARR screening for Mental disorders or Intellectual Disabilities
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- E
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- D
Ensure each resident receives an accurate assessment.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Freedom from Abuse, Neglect, and Exploitation4E
- E
Respond appropriately to all alleged violations.
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Respond appropriately to all alleged violations.
Pharmacy Service4E
- D
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.
- D
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.
- E
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.
- D
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.
Resident Rights4F
- F
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
- D
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.
Infection Control2E
- D
Provide and implement an infection prevention and control program.
- E
Provide and implement an infection prevention and control program.
Nutrition and Dietary1F
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspection history
2026-02-11
11 health deficiencies · 14 fire-safety deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
2024-12-16
9 health deficiencies · 13 fire-safety deficiencies
Top issue: Resident Rights (4 deficiencies)
2023-09-01
15 health deficiencies · 20 fire-safety deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 4 h 33 min of nursing staff time a day, 1 h 36 min of it from a registered nurse.
This home
4 h 33 min
Washington average
4 h 25 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 46% of nursing staff and 27% of registered nurses left in the past year.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine3.8 pts better | 100.0% | 96.2% | 93.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury2.6 pts better | 0.0% | 2.6% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms17.9 pts better | 0.0% | 17.9% | 13.5% |
| Percentage of long-stay residents who lose too much weight4 pts worse | 9.6% | 5.6% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication7.5 pts worse | 20.0% | 12.5% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication8.8 pts better | 6.2% | 15.0% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.1 pts better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose need for help with daily activities has increased2.5 pts worse | 16.3% | 13.8% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder1.8 pts worse | 2.6% | 0.8% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection1.9 pts worse | 3.6% | 1.7% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence12.2 pts better | 9.4% | 21.6% | 18.3% |
| Percentage of long-stay residents with pressure ulcers1.6 pts better | 2.8% | 4.4% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine9.5 pts better | 98.2% | 88.7% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit2 pts better | 11.0% | 13.0% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication0.6 pts better | 0.7% | 1.3% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine10.9 pts better | 95.3% | 84.4% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission1.2 pts worse | 20.9% | 19.7% | 23.4% |
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Who owns and runs it
12 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Covenant Living Communities & Services | Operational/Managerial Control · Organization | 0% | 15 facilities |
| Cunliffe, Terri | W-2 Managing Employee · Individual | 0% | 13 facilities |
| Cunliffe, Terri | Corporate Officer · Individual | 0% | 13 facilities |
| Eastburg, Mark | Operational/Managerial Control · Individual | 0% | 10 facilities |
| Erickson, David | Corporate Officer · Individual | 0% | 13 facilities |
| Espinosa, Marc | Operational/Managerial Control · Individual | 0% | 7 facilities |
| Hodgkinson, Donald | Operational/Managerial Control · Individual | 0% | 7 facilities |
| Holt, Jody | Corporate Officer · Individual | 0% | 10 facilities |
| Manlove, Matt | Operational/Managerial Control · Individual | 0% | 13 facilities |
| Oxendale, Roger | Operational/Managerial Control · Individual | 0% | 10 facilities |
| Stante, Marlene | Operational/Managerial Control · Individual | 0% | 7 facilities |
| Vining, Anne | Operational/Managerial Control · Individual | 0% | 6 facilities |
·
Fire safety
47 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke15F
- F
Provide properly protected cooking facilities.
- F
Have approved installation, maintenance and testing program for fire alarm systems.
- F
Inspect, test, and maintain automatic sprinkler systems.
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
- D
Install an approved automatic sprinkler system.
- F
Provide properly protected cooking facilities.
- F
Have approved installation, maintenance and testing program for fire alarm systems.
- F
Inspect, test, and maintain automatic sprinkler systems.
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- F
Provide properly protected cooking facilities.
- F
Install a fire alarm system that can be heard throughout the facility.
- F
Inspect, test, and maintain automatic sprinkler systems.
- D
Have an enclosure around a vertical opening shaft.
- D
Install corridor and hallway doors that block smoke.
Emergency Preparedness8F
- F
Establish policies and procedures including evacuation.
- F
Address subsistence needs for staff and patients.
- F
Establish policies and procedures for volunteers.
- F
Address subsistence needs for staff and patients.
- F
Establish policies and procedures for volunteers.
- F
List the names and contact information of those in the facility.
- F
Provide family notifications of emergency plan.
- F
Include a process for Emergency Preparedness collaboration.
Miscellaneous6F
- F
Provide a written emergency evacuation plan.
- F
Have simulated fire drills held at unexpected times.
- F
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- D
Have restrictions on the use of portable space heaters.
- F
Have simulated fire drills held at unexpected times.
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Gas, Vacuum, and Electrical Systems6F
- F
Have generator or other power source capable of supplying service within 10 seconds.
- F
Ensure that testing and maintenance of electrical equipment is performed.
- D
Have proper medical gas storage and administration areas.
- F
Have generator or other power source capable of supplying service within 10 seconds.
- F
Ensure that testing and maintenance of electrical equipment is performed.
- F
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Egress5F
- F
Install emergency lighting that can last at least 1 1/2 hours.
- E
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.
- E
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
- F
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
- F
Install emergency lighting that can last at least 1 1/2 hours.
Services5F
- F
Have properly installed electrical wiring and gas equipment.
- F
Have elevators that firefighters can control in the event of a fire.
- D
Install properly constructed and protected linen or trash chutes.
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- D
Have properly installed electrical wiring and gas equipment.
Construction2D
- D
Meet other general requirements.
- D
Meet other general requirements.
·
Other homes nearby
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Kin On Health Care Center
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★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 4 h 23 min
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-
Caroline Kline Galland Home
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- Nursing / resident / day
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-
Washington Care Center
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- G
- Nursing / resident / day
- 3 h 40 min
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- $52,007