Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
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.
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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.
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Nursing homes near Shoreline
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Richmond Beach Rehab | 1.9 mi | — | 23 | 0 |
| Fircrest Nursing Facility | 2.3 mi | — | 23 | 0 |
| Avamere Rehabilitation Of Shoreline | 2.6 mi | — | 11 | 0 |
| Edmonds Post Acute | 2.7 mi | — | 60 | 0 |
| Pine Ridge Post Acute | 2.9 mi | — | 18 | 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 August 2026) and official state health department websites.