C72

COVENANT SHORES HEALTH CENTER

Grade C 72/100 composite score

For profit - Corporation

CMS Star Ratings

Overall
3/5
Health Insp.
3/5
Quality
4/5
Staffing
4/5
RN Staffing
Not rated

Certified Beds

43

Ownership

For profit - Corporation

Total Fines

$190,005

Last Survey

N/A

9107 FORTUNA DRIVE, MERCER ISLAND, WA 98040
2063168042

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
1.35h
LPN
0.19h
CNA
2.54h
Total
4.08h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

COVENANT LIVING COMMUNITIES & SERVICES

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Dec 1975

EASTBURG, MARK

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Jul 2012

ESPINOSA, MARC

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Jul 2012

HODGKINSON, DONALD

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Jul 2012

MANLOVE, MATT

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Jul 2017

OXENDALE, ROGER

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Jul 2017

STANTE, MARLENE

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Jul 2012

VINING, ANNE

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Jul 2012

CUNLIFFE, TERRI

IndividualCORPORATE OFFICERSince Mar 2010

ERICKSON, DAVID

IndividualCORPORATE OFFICERSince Jan 2008

HOLT, JODY

IndividualCORPORATE OFFICERSince Jun 2017

CUNLIFFE, TERRI

IndividualW-2 MANAGING EMPLOYEESince Mar 2009

Penalties & Fines (1)

$190,005total fines
DateTypeDescriptionAmount
Apr 4, 2023Fine$190,005

Health Inspection Deficiencies (40)

December 16, 2024Health9 deficiencies
0578DMinimal harm, Isolated

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.

Resident Rights Deficiencies

Corrected Jan 17, 2025
0610DMinimal harm, Isolated

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Jan 17, 2025
0645EMinimal harm, Pattern

PASARR screening for Mental disorders or Intellectual Disabilities

Resident Assessment and Care Planning Deficiencies

Corrected Jan 17, 2025
0656DMinimal harm, Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Jan 17, 2025
0684DMinimal harm, Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Jan 17, 2025
0552DMinimal harm, Isolated

Ensure that residents are fully informed and understand their health status, care and treatments.

Resident Rights Deficiencies

Corrected Jan 17, 2025
0554DMinimal harm, Isolated

Allow residents to self-administer drugs if determined clinically appropriate.

Resident Rights Deficiencies

Corrected Jan 17, 2025
0623FMinimal harm, Widespread

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Resident Rights Deficiencies

Corrected Jan 17, 2025
0761DMinimal harm, Isolated

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.

Pharmacy Service Deficiencies

Corrected Jan 17, 2025
September 1, 2023Health15 deficiencies
0641DMinimal harm, Isolated

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies

Corrected Sep 29, 2023
0656DMinimal harm, Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Sep 29, 2023
0657EMinimal harm, Pattern

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies

Corrected Sep 29, 2023
0658DMinimal harm, Isolated

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies

Corrected Sep 29, 2023
0688DMinimal harm, Isolated

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.

Quality of Life and Care Deficiencies

Corrected Sep 29, 2023
0689DMinimal harm, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Sep 29, 2023
0758DMinimal harm, Isolated

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.

Pharmacy Service Deficiencies

Corrected Sep 29, 2023
0761EMinimal harm, Pattern

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.

Pharmacy Service Deficiencies

Corrected Sep 29, 2023
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Sep 29, 2023
0645DMinimal harm, Isolated

PASARR screening for Mental disorders or Intellectual Disabilities

Resident Assessment and Care Planning Deficiencies

Corrected Sep 29, 2023
0684DMinimal harm, Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Sep 29, 2023
0686DMinimal harm, Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Corrected Sep 29, 2023
0695DMinimal harm, Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Corrected Sep 29, 2023
0697DMinimal harm, Isolated

Provide safe, appropriate pain management for a resident who requires such services.

Quality of Life and Care Deficiencies

Corrected Sep 29, 2023
0812FMinimal harm, Widespread

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Sep 29, 2023
April 4, 2023Health2 deficiencies1 severe
0880KImmediate jeopardy, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Apr 23, 2023
0835EMinimal harm, Pattern

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Administration Deficiencies

Corrected Apr 23, 2023
June 24, 2022Health14 deficiencies
0881EMinimal harm, Pattern

Implement a program that monitors antibiotic use.

Infection Control Deficiencies

Corrected Jul 26, 2022
0607DMinimal harm, Isolated

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Jul 26, 2022
0641DMinimal harm, Isolated

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies

Corrected Jul 26, 2022
0656EMinimal harm, Pattern

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Jul 26, 2022
0658DMinimal harm, Isolated

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies

Corrected Jul 26, 2022
0689EMinimal harm, Pattern

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Jul 26, 2022
0690DMinimal harm, Isolated

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Quality of Life and Care Deficiencies

Corrected Jul 26, 2022
0700DMinimal harm, Isolated

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.

Quality of Life and Care Deficiencies

Corrected Jul 26, 2022
0758EMinimal harm, Pattern

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.

Pharmacy Service Deficiencies

Corrected Jul 26, 2022
0761DMinimal harm, Isolated

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.

Pharmacy Service Deficiencies

Corrected Jul 26, 2022
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Jul 26, 2022
0578EMinimal harm, Pattern

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.

Resident Rights Deficiencies

Corrected Jul 26, 2022
0825DMinimal harm, Isolated

Provide or get specialized rehabilitative services as required for a resident.

Quality of Life and Care Deficiencies

Corrected Jul 26, 2022
0886EMinimal harm, Pattern

Perform COVID19 testing on residents and staff.

Infection Control Deficiencies

Corrected Jul 26, 2022

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Frequently Asked Questions

What is the CareGrader rating for COVENANT SHORES HEALTH CENTER?

COVENANT SHORES HEALTH CENTER in MERCER ISLAND, Washington has a CareGrader grade of C (Average), with a composite score of 71.8 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for COVENANT SHORES HEALTH CENTER?

COVENANT SHORES HEALTH CENTER has an overall CMS star rating of 3 out of 5, a health inspection rating of 3/5, and a staffing rating of 4/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does COVENANT SHORES HEALTH CENTER have?

COVENANT SHORES HEALTH CENTER has 40 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). View the full inspection timeline above for details on each deficiency.

Has COVENANT SHORES HEALTH CENTER been fined?

Yes. COVENANT SHORES HEALTH CENTER has $190,005 in total fines from CMS enforcement actions across 1 penalty.

How many beds does COVENANT SHORES HEALTH CENTER have?

COVENANT SHORES HEALTH CENTER has 43 certified beds with approximately 37 current residents (86% occupancy). The facility is located at 9107 FORTUNA DRIVE, MERCER ISLAND, Washington 98040. It is a for profit - corporation facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.