Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Covenant Shores Health Center during CMS and state inspections, most recent first.
The facility failed to investigate an unexplained leg fracture for one resident and failed to thoroughly investigate repeated falls for another resident. The first resident, admitted after hip surgery and later found with a fractured upper leg bone, had no incident log or formal investigation, and the DON stated staff did not complete a proper review or interview the resident about possible abuse or trauma. For the second resident, who needed an interpreter and one-person assist, multiple fall investigations were incomplete, with key sections marked N/A, missing neuro checks for unwitnessed falls, conflicting toileting details, and no consistent review of the resident’s stated reasons for falling.
Failure to provide required ADL assistance affected multiple residents who depended on staff for care. One resident with dementia and a broken hip was left sitting in a wheelchair for long periods without repositioning or incontinence checks despite asking to lie down, while three other residents who required staff-assisted bathing were not offered or provided showers as scheduled. Staff and records confirmed missed bathing, repositioning, and incontinence care, and the DON acknowledged the lapses.
Unnecessary antipsychotic use and missing AIMS assessments. A resident with dementia was started on an antipsychotic after a physiatrist visit that noted agitation and possible opiate-induced delirium, but the record showed no documented behaviors before the medication was begun and no infection workup was done to rule out a medical cause. Two other residents were also receiving antipsychotics without baseline AIMS assessments, and one resident’s first AIMS was completed only after the medication had already been stopped.
Failure to log and report an allegation of neglect involving a resident’s unexplained upper leg fracture. The resident was admitted for therapy after hip surgery, had no cognitive impairment, and later had an x-ray-confirmed fracture. Staff did not document or report the injury, and the DON stated there was no trauma identified and the fracture was not investigated.
PASRR screening was not completed as required for two residents. One resident remained in the facility beyond an exempted hospital discharge timeframe, but the level I PASRR was not followed through for the required level II review after it identified a mood disorder. Another resident with Alzheimer’s disease and dementia was started on a new antipsychotic medication for agitation, but no PASRR was completed for the new mood disorder requiring antipsychotic treatment.
The facility failed to complete person-centered care plans and care conferences for multiple residents. A resident receiving hospice services had no hospice care plan or physician order in the record, another resident with repeated falls had no new fall interventions added after some falls, and two residents had no documented care conferences despite being cognitively able to participate or having admission care conference expectations discussed by the DON and social services staff.
Failure to Obtain and Clarify Physician Orders: The facility did not obtain a physician order for hospice services for one resident, did not follow or clarify an O2 order for another resident who received higher O2 flow rates than ordered and had undated O2 tubing, and did not clarify an injectable blood thinner order for a third resident that lacked a stop date or duration. The DON and other staff stated the orders should have been obtained or clarified to ensure continuity of care.
Incomplete Skin Documentation, Missed Bowel Protocol, and Unmanaged Fluid Retention: A resident with dementia and a hip fracture had weekly skin checks marked complete in the chart, but no findings were documented. Another resident with constipation had repeated days without a BM, yet staff did not follow the bowel protocol or notify the MD as ordered. A third resident with HF had rapid weight gain and fluid retention, but the PRN diuretic was not given and the resident was later hospitalized for HF exacerbation.
Unsafe chemical storage on the Rose Unit. Surveyors observed chemicals stored in a resident bathroom, on a hallway wall, on the side of a med cart, and on a hallway railing, with labels indicating the products should be kept out of reach of children. Staff responses varied, but the RN manager, housekeeper, administrator, and DON stated chemicals should be stored behind locked doors or out of residents' reach.
Improper storage and labeling of medications were observed when a resident had pancreatic enzyme capsules at the bedside without a self-administration assessment or order, another resident had eye drops and saline syringes kept at the bedside for self-use, and a medication cart contained an unlabeled cup of 30 tablets without a lid. Staff acknowledged the medications were not properly secured, labeled, or managed per policy.
The facility failed to implement EBP for a resident with an IV device and failed to properly store a urinary catheter bag and perform hand hygiene during catheter care for another resident. Observations showed the IV resident had no EBP in place, while the catheter resident’s bag was on the floor and a CNA used the same dirty gloves during catheter care, touching furniture, the call light, and clothing without hand hygiene or glove changes. The DON confirmed the expected infection control practices were not followed.
The facility failed to provide required written notices to residents and their representatives during hospital transfers, as per their policy. This deficiency was noted for three residents who were transferred multiple times with anticipated returns. The facility's Administrator and DON confirmed the lack of a process for issuing these notices.
The facility failed to accurately complete PASRR assessments for three residents, omitting key mental health diagnoses such as depression and anxiety. This oversight was confirmed by a social worker who acknowledged the need for correction to ensure residents' needs were met.
The facility failed to obtain informed consent for the use of a Tilt-in-Space wheelchair for two residents with severe memory impairments. Both residents were observed using the wheelchair without documentation of informed consent, which was acknowledged as necessary by the DON.
A facility failed to assess a resident's ability to self-administer medications, including an inhaler, ointment, and nasal spray, which were found on the resident's bedside table without proper authorization. The MAR only authorized the inhaler to be kept at the bedside, and there was no assessment in the medical record to ensure the resident could self-administer these medications. Interviews revealed the resident used the inhaler frequently and had not received instructions on medication use. Staff confirmed the lack of physician orders and assessments for the nasal spray and ointment.
The facility failed to maintain Advance Directives (AD) documentation for two residents, one with severe memory impairment and another with intact memory. Despite initial inquiries by a social worker, there was no follow-up to obtain the necessary Durable Power of Attorney (DPOA) paperwork, leaving the facility without critical documentation for healthcare decision-making.
The facility failed to investigate falls and skin injuries for three residents, leading to unresolved causes and inadequate monitoring. A resident with orthostatic hypotension had incomplete neurological checks after falls, while two residents with skin injuries had no root cause identified or documented investigations, despite their medical conditions and communication impairments.
The facility failed to implement comprehensive care plans for residents with complex medical needs, including those requiring supplemental oxygen, restorative programs, diabetes management, edema monitoring, and skin protection. This led to unmet care needs and potential negative health outcomes.
The facility failed to assess the suitability of Tilt-in-Space wheelchairs for two residents with severe memory impairment and mobility issues. Observations showed these residents using the wheelchairs without documented assessments or care plan instructions for their use. Staff interviews indicated that assessments were the responsibility of the therapy department, but no supporting documentation was provided.
The facility failed to secure medications and assess residents' ability to self-administer, as evidenced by observations of three residents with medications left at their bedside without proper assessment or authorization. A resident was found with eye drops and pills unattended, another with prescription ointments and inhalers, and a third with oral anesthetic gel. Staff confirmed that assessments and physician orders were lacking, leading to unsecured medications.
Failure to Investigate Unknown Injury and Repeated Falls
Penalty
Summary
The facility failed to initiate an investigation for an injury of unknown origin involving a resident who had been admitted for therapy after right hip surgery and who later developed severe right upper leg pain and a fractured right upper leg bone. The resident’s MDS showed no cognitive impairment. A social services note documented slow progress and the need for an x-ray because of severe pain, and the x-ray confirmed the fracture. The physician then ordered transfer to the hospital for evaluation of the fracture. Facility records reviewed later showed no incident log for the resident’s January or February events, and the Administrator stated there was no investigation related to the leg fracture. Interviews showed staff did not complete a formal investigation or document staff reports regarding the fracture. The DON stated staff believed the resident may have had the fracture on admission, but this was not supported by a formal investigation. The DON also stated the resident did not experience trauma, falls, or any occurrence since admission, yet this conclusion was reached without interviewing the resident specifically about whether anyone hurt them or documenting a thorough review. The Administrator stated they expected an injury of unknown origin to be investigated. The facility also failed to thoroughly investigate multiple falls for another resident who had a history of falls, required an interpreter for communication, and needed one-person assistance with transfers, mobility, toileting, and dressing. The resident’s care plan listed repeated falls over several months, but the investigations for those falls were incomplete and inconsistent. Several reports marked key sections as N/A, including care provided before the fall, environmental conditions, footwear, call light status, injury and pain assessment, and neurological assessment for unwitnessed falls. Some investigations contained conflicting statements about toileting times or generalized conclusions about the resident’s abilities rather than a specific root-cause review of each fall. The fall investigations also failed to document important details tied to the resident’s own statements, such as trying to get to the bathroom, wash clothes, change clothes, get food or fluids, or remove a jacket because the resident was hot. Staff did not document investigation of those stated reasons, did not consistently assess injuries or pain, and did not complete neurological assessments for unwitnessed falls. The DON stated staff were expected to thoroughly complete incident reports, investigate prior care, environmental factors, call light status, and the resident’s stated reason for falling, but these elements were not consistently addressed in the investigations reviewed.
Failure to Provide Required ADL Assistance
Penalty
Summary
The facility failed to provide assistance with activities of daily living for four residents who were assessed as dependent on staff for care. The deficiency involved bathing, repositioning, toileting hygiene, and incontinence care, with surveyors finding that staff did not consistently provide the assistance required by the residents’ care plans and facility policies. Resident 3 had diagnoses including dementia and a broken hip, was dependent on staff for bed and chair mobility, transfers, and toileting hygiene, and was at risk for pressure ulcers/injuries. The care plan directed staff to check for incontinence, change the resident if wet or soiled, and encourage or assist with frequent repositioning. During observations, Resident 3 remained in a tilt-in-space wheelchair for extended periods after asking to lie down, and staff did not reposition the resident or check for incontinence when returning the resident to the room or during later observations. Staff interviews indicated the resident was typically checked/changed before lunch and when laid down, but one CNA stated they never helped check Resident 3 for incontinence and that the resident often complained about wanting to go to bed. Resident 5 required staff assistance with bathing and had a bathing schedule for twice weekly showers, but the bathing record showed multiple scheduled showers were not offered or provided over several months. Resident 5’s representative stated staff were supposed to assist with showers twice weekly but did not, and that requests for more frequent bathing were not consistently honored. Resident 17 also required staff assistance with bathing, but the resident stated they had not been offered a shower since admission, and the bathing record showed no bathing had been offered or provided for over four weeks. Resident 20 likewise required staff assistance with bathing, had a shower schedule for twice weekly bathing, and both the resident and the bathing record showed no bathing had been offered or provided since admission. Staff acknowledged that the scheduled bathing had not occurred for these residents.
Unnecessary Antipsychotic Use and Missing AIMS Assessments
Penalty
Summary
The facility failed to ensure acute medical delirium was ruled out before an antipsychotic was prescribed for a resident with Alzheimer’s dementia and no documented behavioral issues. Resident 5’s MDS showed no signs of delirium, psychosis, or behavioral concerns, and the resident required an interpreter for communication. A physiatrist visit note documented that the resident was a little agitated during the visit, that no interpreter was provided, and that narcotics for pain were discontinued because staff reported intermittent confusion that was concerning for opiate-induced delirium. The note also recommended an antipsychotic twice daily if there were no concerns for an infectious process. Resident 5’s records showed the antipsychotic was started the same day as the physiatrist visit and continued on the MARs reviewed for the following months. The resident’s records showed no behaviors documented from admission through the review period, and the resident’s bowel records showed a hard BM on the day the medication was started. Staff B stated there was no documentation of behaviors before the antipsychotic was started and that no tests to rule out infection were conducted, although they should have been before starting the medication. Staff B also stated there was no documentation that the physiatrist’s recommendation was reviewed by the primary physician before implementation. The facility also failed to complete baseline AIMS assessments for residents receiving antipsychotic medications. Resident 5 had no AIMS assessment completed before the antipsychotic was started. Resident 13 was admitted on an antipsychotic medication, had dementia without behavioral disturbances or psychotic disorder, and no AIMS assessment was completed on admission. Resident 3 had been receiving an antipsychotic on a routine basis, but the first AIMS assessment found in the record was completed after the medication had already been discontinued. Staff B and Staff C stated they expected AIMS assessments to be completed on admission to establish baseline status, and then at least every six months, but this was not done for these residents.
Failure to Report and Investigate Unexplained Fracture
Penalty
Summary
The facility failed to log and report an allegation of neglect for one resident who developed a right upper leg fracture after admission. The resident was admitted with diagnoses including arthritis, age-related osteoporosis without current pathological fracture, and aftercare following a right hip replacement. The resident’s MDS indicated no delirium and no cognitive impairment. During an interview, the resident stated they came to the facility for therapy after hip surgery and later suffered a right upper leg fracture while recovering. Review of the resident’s x-ray report showed the right upper leg bone fracture occurred two weeks after admission. The facility’s incident log for January and February 2026 did not show the fracture was logged or reported. The DON stated the resident had a high level of pain since admission, that there was no trauma or occurrence identified, and that staff believed the resident may have come to the facility with the fracture; however, the DON also stated the fracture was not investigated. The Administrator stated injuries of unknown origin were reportable incidents.
PASRR Screening Not Completed for Two Residents
Penalty
Summary
PASRR screening for mental disorders or intellectual disabilities was not completed as required for two residents. One resident had a diagnosis of depression and was receiving antidepressant medications; the admission MDS showed staff did not consider the resident to have a serious mental illness through the state level II PASRR process. The resident’s level I PASRR identified a mood disorder and indicated that a level II evaluation was not required because of an exempted hospital discharge, with the form stating that a level II must be completed if the scheduled discharge did not occur. Review of the resident’s comprehensive record showed the resident remained in the facility beyond the exempted hospital discharge timeframe, but staff did not send the level I PASRR for the required level II evaluation. In a staff interview, the Social Service Director stated the facility followed hospital exemption requirements, provided an email showing the level I PASRR had been sent for level II review, and stated they did not receive an evaluation back and had not followed up for nearly eight months. A second resident was admitted with Alzheimer’s disease and dementia without behavioral disturbances and was receiving an antipsychotic medication; physician orders showed the resident was started on a new antipsychotic medication for dementia with agitation, but no PASRR was completed for the new mood disorder requiring antipsychotic medication.
Incomplete Care Plans and Missed Care Conferences
Penalty
Summary
The facility failed to complete person-centered care plans and care conferences as required for several residents. For Resident 41, the 01/01/2026 admission MDS showed diagnoses of malnutrition and heart disease and that hospice services were not being received on admission, yet a 01/08/2026 hospice visit note was present in the record without a hospice care plan or physician order for hospice services. Staff B, the DON, stated staff should have created a hospice care plan but did not. For Resident 5, the 01/24/2026 quarterly MDS showed two or more falls since admission, and the record documented falls on 11/19/2025, 11/25/2025, 12/08/2025, 12/10/2025, 12/24/2025, 01/29/2026 twice, and 02/02/2026; however, the fall care plan did not add new interventions after the 11/19/2025 and 12/08/2025 falls. Staff B stated new interventions were expected with each fall, but they were not added for those events. The facility also did not conduct or document care conferences for two residents. Resident 20, admitted on 02/05/2026 with no memory impairment, was receiving IV antibiotics and had a cancer diagnosis, but stated staff had not offered or conducted a care conference, and the record contained no care conference documentation. Staff B stated admission care conferences were expected to be offered and discussed within one week of admission, but Resident 20 was not offered one. Resident 9, whose 01/03/2026 comprehensive MDS showed a diagnosis involving skeletal muscle breakdown and that the resident could understand and be understood, stated they had not attended a care conference and were frustrated they could not get answers about medications and their condition. Staff E documented that the resident's family member asked to postpone the conference until 01/14/2026, but no record showed that a care conference was ever conducted, and Staff E stated Resident 9 never had one with the IDT.
Failure to Obtain and Clarify Physician Orders
Penalty
Summary
The facility failed to ensure physician orders were obtained and clarified for three sampled residents. Resident 41 was admitted with diagnoses including malnutrition and heart disease, and a hospice visit note dated after admission was present in the record, but the health record did not show a physician order for hospice services. The DON stated staff were expected to obtain a physician order for hospice service and confirmed that staff did not obtain one, although it should have been obtained to ensure continuity of care. Resident 17 was receiving O2 therapy and had a care plan directing staff to administer O2 as ordered. The resident had a physician order for 1 L/min via nasal cannula to keep blood O2 saturation at or above 92 percent, but records showed the resident received 2-3 L/min on multiple dates with no documentation of physician notification, and there was no physician order to change the O2 tubing. Observations showed undated O2 tubing connected to the O2 machine. Resident 6 was admitted with multiple trauma fractures and received an injectable blood thinner during the assessment period, but the physician order for the medication did not include a stop date or direct staff on how long to continue it. Staff reviewed the order and stated it should have been clarified with the physician.
Incomplete Skin Documentation, Missed Bowel Protocol, and Unmanaged Fluid Retention
Penalty
Summary
The facility failed to ensure accurate and complete skin assessments for a resident with dementia and a broken hip who was dependent on staff for bed and chair mobility, transfers, and toileting hygiene and was at risk for pressure injuries. The care plan and physician order required a complete skin assessment once weekly. Review of the treatment administration record showed skin assessments were marked as completed on multiple dates, but no documentation was found showing the actual skin findings for those assessments. During observation, the resident remained seated in a tilt-in-space wheelchair for an extended period. Staff interviews confirmed they could not locate documentation of the resident’s skin condition. The DON stated the electronic record prompted nurses to sign that the skin check was completed, but there was no system to record findings, and although staff had been instructed to use a new skin assessment form, none had been completed for the resident. The facility also failed to implement the bowel protocol for a resident whose bowel pattern was constipation and who was dependent on staff for toileting and transfers. The resident’s representative reported frequent constipation and manual removal of large, hard stools, and records showed repeated days with no bowel movement. Staff reviewed the bowel monitor and medication records and confirmed laxatives were not administered per the bowel protocol or physician orders, and the physician was not notified as required when constipation persisted. In addition, the facility failed to manage fluid retention for a resident with heart failure whose weight increased from 231 lbs to 245 lbs over several days. Although the resident had an order for a PRN diuretic for a 3-lb gain in one day or 5-lb gain in one week, the medication was not given. The resident was later hospitalized for heart failure exacerbation with significant fluid retention, and the family expressed concern about the mismanaged weight gain.
Unsafe Chemical Storage on Rose Unit
Penalty
Summary
The facility failed to ensure chemicals were stored safely on the Rose Unit. During observation and interview on 02/05/2026, surveyors found chemicals in the bathroom of room [ROOM NUMBER], on the wall in the hallway, on the side of the medication cart, and on the hallway railing outside of room [ROOM NUMBER]. The observed chemicals had labels indicating they should be kept out of reach of children. Staff N, an RN, stated chemicals were okay to store in residents' bathrooms, while also stating the chemicals on the hallway railing should not be stored there because staff could misuse them. Staff O, an RN Manager, stated chemicals should not be stored in residents' rooms or within reach of residents. The facility policy titled, Chemical Storage Policies and Procedures, did not instruct staff to store chemicals behind locked doors or out of reach of residents. Staff P, the Lead Housekeeper, stated chemicals should be locked behind a locked cabinet or door. Staff A, the Administrator, stated staff were expected to store chemicals behind locked doors for resident safety. On 02/09/2026, surveyors again observed a disinfectant chemical cleaner on the precaution cart outside of room [ROOM NUMBER], on the hallway wall, and on the side of the medication cart. Staff B, the DON, stated chemicals were expected to be stored behind locked doors and that it was important to do so for resident safety.
Improper Storage and Labeling of Medications
Penalty
Summary
Drugs and biologicals were not secured in accordance with facility policy and accepted storage practices. On observation, Resident 20 had a medication cup at the bedside containing two capsules, which the resident identified as pancreatic enzyme medications and stated were taken only if they ate. Staff stated Resident 20 had not been assessed for safe self-administration, did not have a physician order for self-administration, and was not care planned for it. Resident 37 was observed with a bag of saline syringes hanging on the IV pump pole, a bottle of eye drop medication, and multiple single-use eye drop vials on the bedside table. The resident stated the eye drops were kept there for self-administration, and staff stated the resident had brought the eye drops in on their own and had not had them removed from the bedside. The Rose Medication Cart also contained an unlabeled medication cup with 30 white, round tablets. The cup did not identify the medication name, strength, or expiration date, and it did not have a lid. Staff stated the unlabeled medications were not safe and should be disposed. The facility policy stated medications and biologicals were to be stored in their original packaging or dispensing system and kept locked when not in use, and the DON stated medications should be properly labeled, stored, and locked in the medication cart.
Failure to Implement EBP and Catheter Care Infection Control
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions for a resident with an indwelling medical device. Resident 20 was admitted with diagnoses of cancer and malnutrition and had a physician order for IV medications with a right chest IV device in place. The facility’s August 2022 Enhanced Barrier Precautions policy stated that EBPs were to be used for residents with indwelling medical devices, including central lines and urinary catheters, and were to remain in place for the duration of the resident’s stay or until the device was discontinued. However, Resident 20’s record did not show physician orders for EBP, and observations on 02/05/2026 and 02/06/2026 showed the resident with a right chest IV device and no EBPs in place. The DON stated the resident should have been on EBP for the right chest central IV port but was not. The facility also failed to properly store a urinary catheter bag and perform hand hygiene during catheter care for Resident 13, who had an indwelling urinary catheter. Resident 13’s care plan instructed staff to monitor the catheter bag for proper placement, and the resident had a physician order for urinary catheter care. On observation, the catheter bag was lying on the floor on the right side of the bed and was uncovered. During another observation, a CNA cleaned the resident’s urinary catheter and changed the brief without performing hand hygiene or changing gloves between dirty and clean care, and used the same dirty gloves to touch the resident’s furniture, call light, and clothing. The CNA stated hand hygiene and glove changes should have been done between dirty and clean care, and the DON stated staff were expected to cover and secure catheter bags off the floor and perform hand hygiene and glove changes between dirty and clean care.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide required written notices to residents and their representatives at the time of transfer to the hospital or as soon as practicable, as mandated by their policy. This deficiency was identified for three residents who were reviewed for hospitalization. The facility's policy, dated October 2022, stipulated that for emergent transfers, a Notice of Transfer should be provided in a form and manner understandable to the resident and their representative. However, the records for Residents 28, 5, and 7 showed no documentation of such notices being provided during their multiple hospital transfers. Resident 28 was transferred to the hospital on July 30, 2024, with an anticipated return, but there was no documentation of a written notice of transfer. Similarly, Resident 7 was transferred to the hospital on four occasions between June and October 2024, and Resident 5 was transferred twice in October and November 2024, all with anticipated returns. In each case, there was no documentation of the required written notices being provided. During an interview, the facility's Administrator and Director of Nursing confirmed the absence of a process for providing written transfer notices to residents and their representatives.
Inaccurate PASRR Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate completion of the Pre-Admission Screening and Resident Review (PASRR) assessments for three residents, which is crucial for identifying mental health or intellectual disability needs. Resident 33, who was admitted with a diagnosis of depression and was receiving antidepressant medication, had a PASRR that did not indicate a serious mental illness, as depression was not marked. This oversight was confirmed by Staff C, the social worker, who acknowledged the need for correction to ensure the resident's needs were met. Similarly, Resident 7, who was also diagnosed with depression and receiving antidepressant medication, had a PASRR that only noted anxiety, omitting the depression diagnosis. Resident 2, with diagnoses of anxiety, depression, and bipolar disorder, was receiving multiple medications for these conditions, yet their PASRR only marked mood disorders and did not include anxiety, nor was a Level II evaluation referral made. Staff C admitted to being unaware of the new regulations requiring such referrals, indicating a gap in compliance with the PASRR process.
Failure to Obtain Informed Consent for Medical Device Use
Penalty
Summary
The facility failed to ensure that residents were provided with informed consent regarding the use of a medical device, specifically a Tilt-in-Space wheelchair, for two residents. Resident 31, who had a history of stroke and severe memory impairment, was observed using a Tilt-in-Space wheelchair without documentation of informed consent from their representative. This wheelchair type could potentially restrain the user as the angle could not be adjusted by the user themselves. Similarly, Resident 26, who was assessed with severe memory impairment and complex medical diagnoses including dementia, was also observed using a Tilt-in-Space wheelchair without any documented informed consent. The Director of Nursing acknowledged that the informed consent process should have been completed, with potential risks and benefits explained prior to the use of such a device. The lack of informed consent documentation for both residents placed them at risk for loss of autonomy.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to assess a resident's ability to self-administer medications, which included an inhaler, a tube of ointment, and a nasal spray. Observations showed these items on the resident's bedside table without proper authorization or assessment. The Medication Administration Records (MAR) indicated that only the inhaler was authorized to be kept at the bedside, while the nasal spray and ointment were not. There was no documentation in the resident's medical record to confirm that an assessment had been completed to ensure the resident could self-administer these medications according to the physician's instructions. Interviews with the resident and staff revealed that the resident was using the inhaler frequently and kept it on the bedside table for convenience, as they needed it during the night. The resident stated that they had not received instructions or a demonstration on how to use the medications. Staff confirmed that there were no physician orders for the nasal spray and ointment to be kept at the bedside and that the resident had not been assessed for self-administration. The Director of Nursing acknowledged that a self-medication assessment was missing due to a recent change in the medical records system.
Failure to Maintain Advance Directives Documentation
Penalty
Summary
The facility failed to ensure that two residents had the appropriate Advance Directives (AD) in place, which is a requirement to honor residents' rights regarding medical treatment and end-of-life care. For one resident, who had a history of stroke and severe memory impairment, the facility did not have the Durable Power of Attorney (DPOA) paperwork on file, despite the resident's representative indicating they would provide it. The social worker documented the initial inquiry about the AD paperwork but did not follow up to obtain the necessary documents. For another resident with intact memory, the facility also lacked the DPOA paperwork, even though it was noted on the resident's Face Sheet. The social worker recorded a progress note indicating they would contact the resident's relative to obtain the DPOA paperwork, but no further follow-up was documented. Interviews with the residents and the social worker confirmed the absence of the required documentation and the lack of follow-up efforts to secure it.
Failure to Investigate Falls and Skin Injuries
Penalty
Summary
The facility failed to thoroughly investigate a fall incident involving Resident 88, who was at risk for falls due to complex medical conditions including orthostatic hypotension, atrial fibrillation, and a recent urinary tract infection. The investigation into the unwitnessed fall on December 3, 2024, did not consider orthostatic hypotension as a potential risk factor, despite the resident's low blood pressure reading post-fall. Additionally, neurological checks initiated after a subsequent fall on December 6, 2024, were not completed as required, leaving gaps in monitoring the resident's condition. For Resident 23, the facility did not establish a root cause for skin tears discovered on two separate occasions. The investigations into these injuries of unknown origin did not identify how the skin tears occurred, despite the resident's fragile skin condition and severe memory impairment. The lack of a thorough investigation into these incidents left the cause of the injuries unresolved. Resident 33, who had communication difficulties and memory impairment, was found with undated foam bandages on their forearm and shin, indicating skin injuries. The facility failed to document or investigate these injuries, as there were no incident reports or treatment orders in place. Despite the resident's history of falls, the facility did not log any incidents related to the skin injuries, and staff were unaware of any skin treatments, highlighting a lack of proper investigation and documentation.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to unmet care needs and potential negative health outcomes. Resident 5, who had a heart condition requiring supplemental oxygen, did not have a care plan addressing their oxygen use, including goals or instructions for the concentrator settings and care. Staff acknowledged the absence of a care plan despite the resident's need for supplemental oxygen. Resident 31, with a history of stroke and severe memory impairment, was observed with curled fingers and was supposed to be on a restorative nursing program. However, the care plan lacked details on who was responsible for the program and its frequency. Staff were uncertain about the resident's need for the program, and the Director of Rehabilitation confirmed the resident was on a restorative program. Resident 33, diagnosed with diabetes and communication difficulties, had multiple orders for anti-diabetic medications but no care plan addressing diabetes management. There were no instructions for monitoring blood sugar levels or when to notify a physician. Resident 7, with heart and kidney failure, experienced swelling in their feet, but their care plan did not include monitoring or documenting edema. Lastly, Resident 23, with fragile skin, was observed without protective sleeves despite a care plan indicating their necessity to prevent skin tears. Staff confirmed the need for skin protection but failed to ensure compliance with the care plan.
Failure to Assess Suitability of Tilt-in-Space Wheelchairs
Penalty
Summary
The facility failed to complete a formal assessment prior to the use of a Tilt-in-Space wheelchair for two residents, which is a requirement according to the facility's policy. Resident 26, who has severe memory impairment and complex medical diagnoses including dementia, was observed using a Tilt-in-Space wheelchair labeled with another resident's name. There was no documentation showing that the facility assessed the suitability of this wheelchair for Resident 26. The resident's care plan included an intervention to assist with mobility using the Tilt-in-Space wheelchair but lacked any explanation for its necessity or directions for its appropriate use. Similarly, Resident 31, who has a history of stroke and one-side paralysis, was also observed using a Tilt-in-Space wheelchair without any documented assessment of its suitability. The care plan for Resident 31 provided instructions for using the wheelchair for locomotion but did not explain the need for this specific type of wheelchair or include directions for its proper use. Interviews with staff revealed that assessments were supposed to be completed by the therapy department, but no additional documentation was provided to support that these assessments were conducted.
Failure to Secure Medications and Assess Self-Administration
Penalty
Summary
The facility failed to ensure that medications and biologicals were secured, as evidenced by observations of three residents with medications left at their bedside without proper assessment or authorization to self-administer. Resident 14 was observed on two occasions with lubricating eye drops and a medication cup containing pills on their over-the-bed table. Staff G, a registered nurse, confirmed that they were supposed to stay with the resident until the medications were taken but did not do so. There were no assessments or orders in Resident 14's records indicating they were able to self-administer medications. Resident 29 was observed with a tube of prescription ointment, a prescription nasal spray, and a prescription inhaler at their bedside. The resident stated that staff had not assessed their ability to properly use the inhaler. Staff B, the Director of Nursing, confirmed that residents should have physician orders to keep medications at their bedside and that staff should complete an assessment to ensure safe self-administration. Resident 88 was observed with a tube of oral anesthetic gel on their bedside table, which Staff B stated should not have been there. These observations indicate a failure to secure medications and assess residents' ability to self-administer, as required by regulations.
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 1,305 citations issued within 25 miles in the last 12 months — including the 4 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 Mercer Island
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kin On Health Care Center | 3.8 mi | ★★★★★ | 1 | 0 |
| Caroline Kline Galland Home | 4.2 mi | ★★★★★ | 27 | 0 |
| Washington Care Center | 4.2 mi | ★★★★★ | 30 | 0 |
| Transitional Care Of Seattle | 4.3 mi | ★★★★★ | 49 | 0 |
| Park Shore | 4.9 mi | ★★★★★ | 36 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.