Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

COVENANT SHORES HEALTH CENTER

MERCER ISLAND, WA · 43 certified beds · Last Life Safety survey February 11, 2026

CMS Certification Number 505504 · first certified September 1997

Ownership

Operated by COVENANT LIVING · Non profit - Corporation

No change of ownership on CMS record since January 1, 2016, when the records begin.

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within WA

47 citations — more than 80% of the 193 certified nursing homes in WA. Compared within WA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 14 citations; the earlier surveys in the window averaged 16.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window opens January 2027 — about 4 months from now. This facility’s last Life Safety survey was February 2026. Facilities in WA are typically surveyed 12–15 months after the last one (median 13), measured over 320 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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8 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

8 of the 47 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

4 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 47 Life Safety citations above. The Physical Environment Index

F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F-0880 Provide and implement an infection prevention and control program.

How that compares

Citations on file over three years

Compared with the median facility in WA, and nationally. Surveyors differ markedly between states, so the WA figure is the meaningful one.

Citations on file over three years, compared
Measure	Citations
This facility	47
Median facility in WA	31
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
September 1, 2023	20
December 16, 2024	13
February 11, 2026	14

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0353	Inspect, test, and maintain automatic sprinkler systems.	3	2026-02-11
K-0324	Provide properly protected cooking facilities.	3	2026-02-11
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	2	2026-02-11
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	2	2026-02-11
E-0024	Establish policies and procedures for volunteers.	2	2024-12-16
K-0291	Install emergency lighting that can last at least 1 1/2 hours.	2	2026-02-11
K-0712	Have simulated fire drills held at unexpected times.	2	2026-02-11
K-0511	Have properly installed electrical wiring and gas equipment.	2	2024-12-16

What the citations cover

Citations by CMS category

Smoke Deficiencies 15
Emergency Preparedness Deficiencies 8
Gas, Vacuum, and Electrical Systems Deficiencies 6
Miscellaneous Deficiencies 6
Other 12

Citations by CMS category
Category	Citations
Smoke Deficiencies	15
Emergency Preparedness Deficiencies	8
Gas, Vacuum, and Electrical Systems Deficiencies	6
Miscellaneous Deficiencies	6
Egress Deficiencies	5
Services Deficiencies	5
Construction Deficiencies	2

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

February 11, 2026 — 14 citations

Citations issued on February 11, 2026
Tag	What the surveyor checks	Status
E-0020	Establish policies and procedures including evacuation.	Deficient, Provider has date of correction (March 2, 2026)
K-0100	Meet other general requirements.	Deficient, Provider has date of correction (March 2, 2026)
K-0222	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.	Deficient, Provider has date of correction (March 2, 2026)
K-0291	Install emergency lighting that can last at least 1 1/2 hours.	Deficient, Provider has date of correction (March 2, 2026)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (March 2, 2026)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (March 2, 2026)
K-0351	Install an approved automatic sprinkler system.	Deficient, Provider has date of correction (March 2, 2026)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (March 2, 2026)
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	Deficient, Provider has date of correction (March 2, 2026)
K-0711	Provide a written emergency evacuation plan.	Deficient, Provider has date of correction (March 2, 2026)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (March 2, 2026)
K-0741	Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.	Deficient, Provider has date of correction (March 2, 2026)
K-0781	Have restrictions on the use of portable space heaters.	Deficient, Provider has date of correction (March 2, 2026)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (March 2, 2026)

December 16, 2024 — 13 citations

Citations issued on December 16, 2024
Tag	What the surveyor checks	Status
E-0015	Address subsistence needs for staff and patients.	Deficient, Provider has date of correction (January 10, 2025)
E-0024	Establish policies and procedures for volunteers.	Deficient, Provider has date of correction (January 10, 2025)
K-0223	Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.	Deficient, Provider has date of correction (January 10, 2025)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (January 10, 2025)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (January 16, 2025)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (January 16, 2025)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (January 10, 2025)
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	Deficient, Provider has date of correction (January 10, 2025)
K-0511	Have properly installed electrical wiring and gas equipment.	Deficient, Provider has date of correction (January 10, 2025)
K-0531	Have elevators that firefighters can control in the event of a fire.	Deficient, Provider has date of correction (January 10, 2025)
K-0541	Install properly constructed and protected linen or trash chutes.	Deficient, Provider has date of correction (January 10, 2025)
K-0921	Ensure that testing and maintenance of electrical equipment is performed.	Deficient, Provider has date of correction (January 10, 2025)
K-0923	Have proper medical gas storage and administration areas.	Deficient, Provider has date of correction (January 10, 2025)

September 1, 2023 — 20 citations

Citations issued on September 1, 2023
Tag	What the surveyor checks	Status
E-0009	Include a process for Emergency Preparedness collaboration.	Deficient, Provider has date of correction (September 29, 2023)
E-0015	Address subsistence needs for staff and patients.	Deficient, Provider has date of correction (September 29, 2023)
E-0024	Establish policies and procedures for volunteers.	Deficient, Provider has date of correction (September 29, 2023)
E-0030	List the names and contact information of those in the facility.	Deficient, Provider has date of correction (September 29, 2023)
E-0035	Provide family notifications of emergency plan.	Deficient, Provider has date of correction (September 29, 2023)
K-0100	Meet other general requirements.	Deficient, Provider has date of correction (September 29, 2023)
K-0225	Have stairways and smokeproof enclosures used as exits that meet safety requirements.	Deficient, Provider has date of correction (September 29, 2023)
K-0291	Install emergency lighting that can last at least 1 1/2 hours.	Deficient, Provider has date of correction (September 29, 2023)
K-0311	Have an enclosure around a vertical opening shaft.	Deficient, Provider has date of correction (September 29, 2023)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (September 29, 2023)
K-0341	Install a fire alarm system that can be heard throughout the facility.	Deficient, Provider has date of correction (September 29, 2023)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Waiver has been granted (September 29, 2023)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (September 29, 2023)
K-0511	Have properly installed electrical wiring and gas equipment.	Deficient, Provider has date of correction (September 29, 2023)
K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Deficient, Provider has date of correction (September 29, 2023)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (September 29, 2023)
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	Deficient, Provider has date of correction (September 29, 2023)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (September 29, 2023)
K-0921	Ensure that testing and maintenance of electrical equipment is performed.	Deficient, Provider has date of correction (September 29, 2023)
K-0926	Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.	Deficient, Provider has date of correction (September 29, 2023)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.