Bridges To Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Shoreline, Washington.
- Location
- 18904 Burke Ave N, Shoreline, Washington 98133
- CMS Provider Number
- 505535
- Inspections on file
- 7
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 38
Citation history
Health deficiencies cited at Bridges To Home during CMS and state inspections, most recent first.
A resident with chronic respiratory failure and a tracheostomy experienced a decannulation event in which the trach flange broke, a trach tie was off, and the resident’s O2 saturation dropped before returning to baseline. Facility records and staff interviews showed that, despite a policy requiring notification of resident representatives within 24 hours of incidents or changes in condition, the resident’s representatives were not informed of this event until weeks later. A hospital note documented that the representatives reported they had not been told of the incident until much later and felt unheard and dismissed, demonstrating a failure to ensure the resident and representatives were fully informed about the resident’s health status, care, and treatment.
The facility failed to timely report an allegation of abuse/neglect after a resident on droplet precautions, ordered to remain in their room except for bathing, was directed by a senior clinical leader to be brought into common and play areas despite staff reminders about the MD order and infection policy. An RN ultimately complied, and the resident, who could understand language, was present when the leader, speaking in an elevated and agitated tone, stated they would "rather have sick babies than dead babies," a comment the facility’s investigation found implied harm and did not rule out abuse. The investigation also determined that ignoring the known MD order meant neglect was not ruled out. Although the facility’s policy and the DON required reporting such allegations to the State Agency within 24 hours, the incident was not reported until several days later, and one staff member did not report it at the time because they believed "everybody knew about it."
A resident on droplet precautions for respiratory symptoms had a physician order to remain in their room except for bathing, but an administrator directed staff to disregard the order and infection control policy and bring the resident into common areas. Staff informed the administrator of the active droplet precautions, yet the directive was repeated and followed, and the resident was present during a contentious exchange in which the administrator made a statement implying harm. The DON and administrator later acknowledged that this allegation of abuse/neglect was not investigated within the required timeframe, and the administrator did not interview the resident, the resident’s representatives, or other residents or representatives, resulting in a delayed and incomplete investigation contrary to facility policy and regulatory requirements.
A resident with respiratory symptoms and a physician’s order for droplet precautions had a care plan requiring them to remain in their room except for bathing. Despite this, the resident was observed in a common area and then taken by the Activity Director to a shared playroom, where they were supervised, although no other residents were present. The DON later stated that staff were expected to follow the care plan and that the resident should not have left the room, demonstrating a failure to implement the ordered droplet precaution care plan.
The facility did not ensure adequate dietary staffing, as only one Nutrition Services Manager was responsible for all kitchen functions, including manager, cook, and housekeeping roles. The facility assessment did not account for the number of cooks needed, despite two residents receiving oral intake in addition to tube feeding, one with frequent oral meals and another on a restricted-calorie diet. Because the Nutrition Services Manager worked every other day, meals were prepared in advance and reheated by an aide on days they were absent, rather than being freshly prepared each day. The Program Administrator confirmed that this was the only kitchen staff member, that concerns about staffing shortages and the need for a cook had been raised, and that there was no timely response from higher management.
Failure to Timely Notify Resident Representative of Significant Respiratory Event
Penalty
Summary
The deficiency involves the facility’s failure to timely inform a resident and/or their representative of a significant change in health status and treatment event. The resident was admitted with chronic respiratory failure and had a tracheostomy in place. A progress note documented that on 01/21/2026 the resident experienced a decannulation event when the tracheostomy flange broke and one trach tie was found off, during which the resident’s oxygen saturation dropped to 84% before returning to their baseline of 94%–96%. This event constituted a change in the resident’s condition and involved their respiratory support and tracheostomy management. Interview and record review showed that the facility did not notify the resident’s representatives of this decannulation incident within the facility’s stated 24-hour notification timeframe. The social worker reported receiving an email about the event after hours on 01/21/2026 but acknowledged that the resident’s representatives were not actually notified until 02/13/2026. The program administrator confirmed that facility policy required notification of the family and/or resident representatives within 24 hours of an incident and acknowledged that notification in this case was late. A hospital note dated 03/02/2026 documented that the resident’s representatives told the hospital physician they were not informed of the 01/21/2026 event until 02/13/2026 and felt unheard and dismissed. This failure to provide timely information to the resident’s representatives constituted noncompliance with WAC 388-97-0260 regarding resident rights to be fully informed of their health status, care, and treatments.
Failure to Timely Report Alleged Abuse/Neglect Related to Droplet Precautions
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse and/or neglect to the State Agency within the required timeframe, as mandated by facility policy and state regulations. The facility’s Abuse and Neglect Prevention and Reporting policy, revised in February 2026, states that all suspected, alleged, or actual cases of abuse or neglect, including injuries of unknown origin, must be thoroughly investigated and reported according to state and federal regulations, with reporting required within 24 hours. Staff B, the DON, and Staff A, the Program Administrator, both acknowledged that an allegation of neglect related to a resident’s physician‑ordered droplet precautions occurred on 02/16/2026 but was not reported to the State Agency until 02/23/2026, outside the required timeframe. Resident 1 had a physician order dated 02/11/2026 for droplet precautions due to runny nose and increased secretions, requiring the resident to remain in their room and only leave for bathing. On 02/16/2026, an incident occurred in which Staff D, the Associate Executive Director for Clinical Operations, instructed Staff C, the Activity Director, and Staff E, an RN, to disregard the physician’s droplet precaution order and the facility’s infection policy by bringing the resident out of their room into the common area and later into a shared playroom. Both Staff C and Staff E informed Staff D that the resident was on droplet precautions, but Staff D insisted the resident be brought out of isolation. Staff E ultimately complied, and the resident, who could understand language, was present during a verbal interaction between Staff D and Staff C. During this interaction, when Staff C objected and offered to don PPE and remain in the resident’s room instead of bringing the resident into the community areas, Staff D responded, “I would rather have sick babies than dead babies.” The facility’s investigation documented that this statement implied harm to the resident and that abuse was not ruled out. The investigation further concluded that, because a physician’s order was known and there was no reason not to follow it, others were placed at risk and the neglect allegation was not ruled out. Staff C later stated in interview that they knew taking the resident, who was not wearing a mask, into the common area was against the physician’s order and did not report the incident because “everybody knew about it.” Staff B and Staff A both confirmed in interviews that the allegation should have been reported to the State Agency in a timely manner as required by the facility’s policy and the Purple Book guidelines, but it was not.
Failure to Timely and Thoroughly Investigate Alleged Abuse/Neglect Related to Droplet Precautions
Penalty
Summary
The deficiency involves the facility’s failure to timely and thoroughly investigate an allegation of abuse and neglect related to a resident on droplet precautions. Facility policy and the Purple Book guidelines require that all alleged incidents of abuse, neglect, mistreatment, injuries of unknown source, or exploitation be thoroughly investigated, with an initial investigation completed within 24 hours and a full investigation within five days of the incident. Despite these requirements, an allegation arising from an incident involving a resident with a physician’s order for droplet precautions was not investigated within the required timeframe. The resident had a physician order dated 02/11/2026 for droplet precautions due to runny nose and increased secretions, specifying that the resident was to remain in their room and could leave only for bathing. On 02/16/2026, the resident was taken out of their room and remained in the facility’s common area and later in a shared playroom. According to the incident investigation report, the Associate Executive Director for Clinical Operations (Staff D) instructed the Activity Director (Staff C) and an RN (Staff E) to disregard the physician’s droplet precaution order and the facility’s infection policy, and to bring the resident out of isolation. Staff C and Staff E each informed Staff D that the resident was on droplet precautions, but Staff D insisted the resident be brought out, and Staff E ultimately complied. The resident, who was reported to understand language and repeat what staff say, was present during a verbal interaction in which Staff D stated, “I would rather have sick babies than dead babies,” and the investigation document noted that abuse and neglect could not be ruled out. Interviews showed that the Director of Nursing (Staff B) and the Program Administrator (Staff A) acknowledged that the allegation of neglecting the physician‑ordered droplet precautions occurred on 02/16/2026, but the investigation was not completed until 02/25/2026. Staff B stated they were in the facility when the incident occurred, that the Program Administrator was on leave, and that the investigation was delayed until the Program Administrator returned, contrary to the policy requiring investigation within 24 hours. Staff A confirmed responsibility for the investigation, acknowledged the delay, and stated they were not able to rule out abuse and neglect. Staff A also stated they did not interview the resident, the resident’s representatives, or other residents or their representatives to assess potential harm or impact, despite knowing that the resident could understand and repeat language. This failure to initiate and complete a timely and thorough investigation, including appropriate interviews, constituted noncompliance with the facility’s abuse and neglect investigation policy and applicable regulations.
Failure to Follow Droplet Precaution Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to implement a comprehensive, person-centered care plan for a resident who was placed on droplet precautions. The facility’s policy required the IDT to develop and implement such a care plan. A physician’s order dated 02/11/2026 directed that the resident be on droplet precautions due to respiratory symptoms, including a runny nose and increased secretions, and specified that the resident was to remain in their room and could leave only for bathing. The resident’s care plan, printed on 03/25/2026, reflected these orders, stating that the resident was recovering from respiratory symptoms, was on droplet precautions, and was to remain in their room except when leaving for bathing. Despite these orders and the care plan, an incident investigation report dated 02/25/2026 documented that on 02/16/2026 the resident was observed outside their room in the facility’s common area and later in a shared playroom. The investigation showed that the physician’s order for droplet precautions and room restriction was not followed. During an interview, the Activity Director stated they observed the resident in the common area and, following instructions, took the resident to the shared playroom and supervised them there, noting that no other residents were present in either area at that time. In a separate interview, the DON stated they expected staff to follow residents’ care plans, including droplet precaution care plans, and confirmed that the resident should not have left their room.
Insufficient Dietary Staffing Resulting in Lack of Freshly Prepared Meals
Penalty
Summary
The facility failed to ensure sufficient dietary support personnel were available to carry out food and nutrition services, as identified through observation, interview, and record review. The facility assessment revised on 01/13/2026 did not plan for the number of cooks needed to meet food and nutrition service requirements. Physician orders showed that one resident was to take meals orally four times daily, and another resident had a restricted diet of 60 calories per day. Both residents received some oral intake in addition to tube feeding, with one resident on a plan to gradually discontinue tube feeding and the other receiving oral food for pleasure feeding. On 03/05/2026, the Nutrition Services Manager reported working alone in the kitchen and being responsible simultaneously for the duties of Dietary Manager, cook, and kitchen housekeeping. This staff member stated they prepared meals in advance for the following day because they only worked every other day, resulting in residents not receiving freshly prepared meals daily and having their meals reheated by an aide when the Nutrition Services Manager was not present. The Program Administrator confirmed that there was only one staff member assigned to the kitchen, acknowledged that this staff member had raised concerns about kitchen staffing shortages and the need for a cook, and stated that higher management had not provided a timely response to requests to hire additional dietary staff.
Latest citations in Washington
Inaccurate PASARR screening affected two residents. One resident with vascular dementia, depression, and adjustment disorder had a PASARR level one that did not reflect mental health diagnoses, and staff stated it was inaccurate. Another resident with PTSD had a PASARR level one that did not include the PTSD diagnosis, with no additional PASARR level one or level two found in the EHR; staff stated the screening was not accurate and should have been repeated.
Undated open meds were found on 2 medication carts, including an open insulin vial and multiple open eye drop bottles with no dates. An LPN and an RN both stated the items should have been dated when opened, and the DON stated open multidose vials or bottles found without a date should be discarded immediately.
A resident with respiratory failure, HTN, and anxiety became SOB and diaphoretic, received a breathing tx, and was sent by EMS to the hospital. The facility could not locate the required SNF/NF to Hospital Transfer form or other transfer records showing what information was communicated to the receiving provider.
Care plans for two residents were not updated to match their current status and care needs. One resident had PTSD and generalized anxiety disorder and was receiving a psychotropic medication, but the care plan listed monitoring for antipsychotic and anticonvulsant meds that were not prescribed and did not include the anxiety diagnosis or related behaviors and interventions. Another resident had new upper and lower dentures, but the oral/dental care plan only noted edentulous status and difficulty chewing, with no mention of dentures or denture-related interventions.
Failure to Provide Individualized Activities: A resident with anxiety, depression, and weakness was cognitively intact but said they could not attend group activities because of leg problems and wanted more in-room activities. The resident mostly stayed in bed watching TV, and staff documentation showed only limited room visits with no consistent activity documentation despite a care plan goal for participation two to three times per week.
Failure to maintain heel offloading for a resident with a reopened DFU. A resident with dementia and dependence for mobility had a left heel wound that had healed and then reopened; the wound care provider recommended heel floating and pressure relieving boots at all times, but observations showed the resident in bed with heels on the mattress and later reclined in a wheelchair with the heel resting on the footrest strap and no boots in place. Staff stated the resident had not refused the boots or heel floating, and the care plan was not updated after the wound reopened.
Failure to Address Hearing and Vision Services for a Resident: A resident with dementia, bilateral hearing loss, and impaired vision was observed without eyeglasses or a hearing device, despite records showing admission with eyeglasses and a personal sound amplifier. The care plan addressed vision only and did not include hearing-related interventions, while staff interviews confirmed the resident’s hearing was strained and that the resident’s device use and vision needs were not fully reflected in the plan of care.
Respiratory care was not provided consistently for two residents receiving O2. One resident with COPD and chronic respiratory failure had an O2 order missing the indication for use and Sats parameters, no MAR documentation of O2 therapy, and inconsistent Sats charting. Another resident with respiratory failure was observed on continuous O2 via NC, but provider orders for O2 therapy and tubing changes were not present after readmission, despite the care plan stating the resident was dependent on O2.
A resident with dementia, hearing loss, and missing lower teeth had an MDS showing obvious or likely cavities or broken natural teeth, and the care plan identified oral/dental health problems with an intervention to coordinate dental care and transportation. Staff stated the resident’s dental needs were captured on the MDS, but no referral was made for dental services or follow-up with the dentist, and the DON said the lack of referral did not meet expectations.
Inaccurate Meal Intake Documentation: A resident with DM, dysphagia, and protein-calorie malnutrition was observed eating less than 25% of a meal, but the POC documented 76-100% intake. The CNA said the resident usually ate only 25-50% of meals and that intake was sometimes documented based on what a coworker reported. The LPN/RCM and DON stated meal intake should be documented accurately.
Inaccurate PASARR Screening for Two Residents
Penalty
Summary
The facility failed to ensure that two residents were screened for additional mental health supports through the PASARR process. Resident 97 was admitted with diagnoses including vascular dementia, depression, and adjustment disorder, and was able to make needs known. Review of the PASARR level one dated 04/10/2026 showed no mental health diagnoses and no need for a PASARR level two, even though the resident’s record included mental health diagnoses. During interview, the Regional Social Services staff and the Administrator stated the PASARR was inaccurate, needed modifications, and did not meet expectations. Resident 6 was admitted with diagnoses including heart failure, respiratory failure, and PTSD, and was able to make needs known. Review of the PASARR level one dated 03/30/2026 showed no serious mental illness indicators marked and no PASARR level two indicated, and the EHR contained no other documented PASARR level one or level two. The Social Services Director stated the hospital-provided PASARR was reviewed for accuracy and, if inaccurate, another level one would be completed, and stated this resident’s PASARR did not include PTSD and should have had another level one completed. The Administrator also stated the PASARR was not accurate and another level one needed to be conducted, but none could be located in the EHR.
Undated Open Medications on Medication Carts
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications for 2 of 3 sampled medication carts reviewed for medication storage and labeling, including carts on the 400 and 500 halls. On the 500 hall medication cart, an open vial of insulin and an open bottle of eye drops were observed with no dates. During interview, an LPN stated that when an insulin vial or bottle of eye drops is opened, it should be dated immediately and said both items should have been dated upon opening; the LPN stated they would dispose of the undated vial and bottle. On the 400 hall medication cart, two open bottles of eye drops were observed with no dates. During interview, an RN stated both bottles should have been dated as soon as they were opened and said they would get new eye drops and dispose of the undated bottles. The DNS/RN stated that if an eye drop was opened it should have been dated immediately and that any open multidose vial or bottle found without a date should be discarded immediately.
Missing Hospital Transfer Documentation
Penalty
Summary
The facility failed to ensure hospital transfer documentation was completed for one resident who was transferred to the hospital after complaining of not being able to breathe and appearing diaphoretic. The resident had diagnoses of respiratory failure, high blood pressure, and anxiety disorder, and was able to make needs known. A breathing treatment was provided, and the provider agreed to send the resident out for further evaluation, after which emergency transportation took the resident to the hospital. Record review found no documentation showing what information was provided or communicated to the receiving facility for the transfer. Staff stated that transfer documentation should have included a SNF/NF to Hospital Transfer form, the resident's face sheet, and the medication and treatment administration records, but they were unable to locate documentation showing these items were completed or sent for the resident's hospital transfer.
Care plans did not reflect current diagnoses, medications, or denture status
Penalty
Summary
The facility failed to ensure that care plans were revised and accurately reflected residents’ current status and care needs for 2 of 21 sampled residents. Resident 6 was admitted with diagnoses including heart failure, respiratory failure, and PTSD, and was able to make needs known. The EHR showed Resident 6 also had generalized anxiety disorder and was receiving a psychotropic medication, but the current care plan dated 05/05/2026 documented monitoring for side effects of antipsychotic and anticonvulsant medications even though Resident 6 was not prescribed those medications. The care plan also identified PTSD but did not include generalized anxiety disorder or behaviors to monitor and interventions related to PTSD or anxiety disorder. Staff F, LPN/CC, stated the care plan did not accurately reflect the resident’s current status or prescribed medications, and Staff B, DNS, stated it did not meet expectations because it did not address the anxiety disorder or target behaviors and interventions. Resident 71 was admitted with diagnoses including PTSD, high blood pressure, and depression and was able to make needs known. Observation on 05/06/2026 showed a denture cup by the sink with the resident’s name on the lid and new upper and lower dentures dated 01/12/26. The resident stated the lower dentures did not fit well and that denture adhesive had been provided, but the dentures still did not fit right and the resident had not told staff yet. The focused oral/dental care plan, initiated on 06/23/2026, identified the resident as edentulous and having difficulty chewing, but did not show that the resident had dentures or include interventions related to denture use or maintenance. Staff E, CNA, stated they had not seen the resident wear dentures and were unaware of the new dentures, Staff C, LPN/CC, stated the care plan should have been updated when the dentures were obtained, and Staff B, DNS, stated the care plan should have reflected the dentures and interventions.
Failure to Provide Individualized Activities
Penalty
Summary
The facility failed to provide individualized activities for Resident 5, who was admitted with diagnoses including anxiety disorder, depression, and weakness. The admission MDS dated 01/14/2026 showed the resident was cognitively intact. During interviews on 05/03/2026 and 05/06/2026, Resident 5 stated they could not attend in-person activities because of their legs, wanted more activities to occupy them, mostly stayed in bed watching TV, and did not remember the last time activities staff visited to offer activities. The resident also stated activities staff would need to offer something they were able to do because they had difficulty doing some activities. The activities care plan dated 12/26/2026 showed a goal for Resident 5 to participate in activities two to three times per week. Progress notes documented one visit on 12/22/2026 to provide a welcome packet and encourage participation in daily activities, but no further activity documentation was found in the progress notes. Staff H stated room visits should include puzzles, arts and crafts, visiting, and chatting, and that documentation was placed in tasks, but the task record showed no documentation of activities for the past 30 days. Staff J stated paper documentation existed for room visits and that Resident 5 was on a list for room visits every Monday and Wednesday, while the room visit documentation showed only four visits on 01/26/2026, 02/06/2026, 03/10/2026, and 04/08/2026.
Failure to Maintain Heel Offloading for Reopened DFU
Penalty
Summary
The facility failed to consistently implement pressure reducing strategies for a resident with a left heel diabetic foot ulcer that had reopened. The resident was admitted with diagnoses including left hip fracture with surgical repair, a blood clot of the left lower leg, and dementia, and was dependent on staff for mobility and unable to make needs known. The baseline care plan and care plan both included heel offloading interventions, and the wound care provider initially recommended heel floating with pillows or wedge and pressure relieving boots. The wound later resolved, but a weekly skin assessment documented that the left heel wound reopened and was very painful to touch. After the wound reopened, the contracted wound care provider documented that the DFU to the left heel had reopened and recommended the resident wear pressure relieving boots at all times. The current care plan reviewed after the wound reopened did not include new interventions related to the reopened wound. Observations showed the resident seated in a reclined wheelchair with the left foot/heel resting on the footrest strap and no pressure relieving boots in place, and later lying in bed with both heels directly on the mattress without being floated and without boots. Staff interviews indicated the resident had not refused the boots or heel floating, and the LPN/CC and DON stated the resident should have been assessed and the plan of care updated when the wound reopened.
Failure to Address Resident Hearing and Vision Needs
Penalty
Summary
The facility failed to address one resident’s hearing and vision needs. Resident 112 was admitted with diagnoses including a leg fracture, dementia, and hearing loss in both ears, and was able to make needs known. The record showed the resident lost their glasses and was given readers, but the resident did not wear them because they were concerned that wearing glasses that were not their prescription would further degrade their vision. Observation did not show glasses in the resident’s room, and the resident stated they did not use a hearing aid. The resident was observed to be hard of hearing, requiring an elevated voice and repeated questions to understand. The admission MDS dated [DATE] documented adequate hearing with hearing aid and adequate vision with corrective lenses, while the significant change MDS dated [DATE] documented moderate difficulty hearing without a hearing aid and impaired vision without corrective lenses. The care plan initiated 02/24/2026 addressed impaired vision with interventions to arrange consultation with eye care practitioners as needed and remind the resident to wear glasses, but it did not include a focus area or interventions for hearing loss or use of hearing aids. A resident clothing list showed the resident admitted with one pair of eyeglasses and one Super Ear headset personal sound amplifier, yet observation and interview showed the resident in bed without eyeglasses or a hearing device, with the amplifier stored in the bedside table drawer. Staff interviews confirmed the resident’s hearing was strained, that the hearing device and glasses were not being used, and that the resident’s hearing device use should have been included in the plan of care and the resident should have been referred for eye care assessment.
Respiratory Care Orders and Documentation Not Maintained
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for two residents receiving oxygen therapy. One resident with COPD and chronic respiratory failure with hypoxia was observed multiple times lying in bed receiving oxygen at 2 L via nasal cannula. The resident’s oxygen order, dated 02/15/2026, allowed 1 to 4 L per minute continuously via nasal cannula, but it did not include an indication for use or oxygen saturation parameters. The April and May 2026 MARs did not show documentation of oxygen therapy being provided, and the TARs showed only an order to change oxygen tubing if damaged or visibly soiled, not an order for oxygen therapy. Oxygen saturations were not documented consistently daily from 04/01/2026 through 05/04/2026. A second resident with respiratory failure, high blood pressure, and anxiety disorder was observed in the room receiving oxygen at 6 L via nasal cannula on multiple occasions. The resident stated they needed oxygen therapy to breathe, and the care plan identified the resident as dependent on oxygen and to receive oxygen per provider orders. However, provider orders reviewed on 05/04/2026 showed no orders for oxygen therapy or for changing oxygen tubing. Staff stated the oxygen and tubing-change orders had been discontinued when the resident went to the hospital and were not added back to the MAR or TAR when the resident readmitted to the facility.
Failure to Refer Resident With Identified Dental Needs
Penalty
Summary
The facility failed to ensure that Resident 112 received needed dental care. Resident 112 was admitted with diagnoses including a leg fracture, dementia, and hearing loss in both ears. Observation on 05/03/2026 showed the resident had missing lower teeth. The admission MDS, dated [DATE], documented obvious or likely cavities or broken natural teeth, and the care plan dated 02/24/2026 identified oral/dental health problems related to likely cavities or broken teeth with an intervention to coordinate dental care and provide transportation. During interviews, Staff G, Regional Social Services, stated Resident 112's dental needs were captured on the 02/24/2026 MDS and the resident was not referred for dental services. Staff M, Social Services Director, stated residents with dental needs should be referred to social services to be scheduled for assessment by a dental care practitioner, and that Resident 112 should have been referred after the MDS assessment. Staff B, DON, stated residents with identified dental needs should be referred for follow-up with a dentist and that Resident 112 should have been referred to the in-house dental provider; Staff B stated the lack of referral did not meet expectations.
Inaccurate Meal Intake Documentation
Penalty
Summary
The facility failed to accurately document the amount of food eaten for Resident 13, who was admitted with diagnoses including diabetes mellitus, dysphagia, and protein-calorie malnutrition. The quarterly MDS dated 02/12/2026 showed the resident was moderately cognitively impaired. During observation on 05/05/2026 at 12:09 PM, a meal tray was delivered to the resident’s room, set up on a bedside table, and the resident was observed eating slowly, eating less than 25% of the meal, then laying back in bed and closing their eyes while the tray remained in the room. Staff later removed the tray, but the POC documentation for lunch on 05/05/2026 recorded that Resident 13 ate 76-100% of the meal. During interview, the CNA stated the resident typically ate 25-50% of meals and never ate all of the food, and that if they did not pick up a tray they would ask a coworker what the resident ate before documenting it. The CNA stated they were told the resident ate 75-100% of lunch, so that is what was entered. The LPN/RCM stated staff should document meal intake accurately in POC, and the RN/DNS stated it was their expectation that all staff document meal intake accurately.
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