Gig Harbor Memory Care.

citations were written under 388-78A- 2130 (service agreement planning), 388-78A-2150 (signing of the service agreement), 388-78A-2120 (monitoring well being) and 388-78A- 2210 (medication services). Conclusion / Action: . Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . . . . . . . .

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION Statement of Deficiencies License #: 2627 Compliance Determination # 53837 Plan of Correction Gig Harbor Memory Care Completion Date You are required to be in compliance at all times with all licensing laws and regulations to maintain your Assisted Living Facility license. The department completed data collection for an unannounced on-site complaint investigation on 01/28/2025 of: Gig Harbor Memory Care 3025 14TH AVE NW GIG HARBOR, WA 98335 This document references the following complaint number(s): 163430, 163851 The following sample was selected for review during the unannounced on-site visit: 10 of 0 current residents and 0 former residents. The department staff that investigated the Assisted Living Facility: Michael Goulet, Complaint Investigator From: DSHS, Aging and Long-Term Support Administration Lakewood, WA 98496 . 02/18/2025 . Statement of Deficiencies License #: 2627 Compliance Determination # 53837 Plan of Correction Gig Harbor Memory Care Completion Date As a result of the on-site visit(s), the department found that you are not in compliance with the licensing laws and regulations as stated in the cited deficiencies in the enclosed report. I understand that to maintain an Assisted Living Facility license, the facility must be in compliance with all the licensing laws and regulations at all times. Administrator (or Representative) Date WAC 388-78A-2600 Policies and procedures. (2) The assisted living facility must develop, implement and train staff persons on policies and procedures to address what staff persons must do: U) To appropriately respond to aggressive or assaultive residents, including, but not limited to: (i) Actions to take if a resident becomes violent; (ii) Actions to take to protect other residents; and (iii) When and how to seek outside intervention. This requirement was not met as evidenced by: Based on interviews and records review, the Assisted Living Facility (ALF) failed to ensure the safety of 6 of 10 residents sampled (Residents 2, 3, 4, 5, 6 and 7 [R2, 3, 4, 5, 6, and 7)) by failing to appropriately address the aggressive behavior of one resident (Resident 1 [R1]). This failure placed all facility residents at risk of physical harm, and allowed residents to be assaulted (Residents 2, 3, 4, 5, 6 and 7) and/or injured (Residents 3, 5, 6 and 7) as a direct result of the behavior of Resident 1. Findings Included ... During an interview on 01/28/2025 at 11:00am, Staff B, facility Med Tech stated that R1 had not been compliant with taking the behavioral medication (Olanzapine, antipsychotic medication) which had been prescribed for R1 prior to their admission to the facility ( /2024). Staff B stated that R1's primary care physician had been informed of R1's refusal to take their behavioral medication, and that the only change the physician had made was to alter the indication for this medication from 'scheduled' Statement of Deficiencies License #: 2627 Compliance Determination # 53837 Plan of Correction Gig Harbor Memory Care Completion Date (given daily at specific time) to 'PRN' (given only 'as needed'). When asked if this change to the medication indication was effective, Staff B stated, "Sometimes he (R1) will take his meds, mostly he will not." During an interview on 02/05/2025 at 10:10am, Staff A, facility Resident Care Coordinator stated that R1 "was supposed to be on behavioral medication, but he refused to take it. He (R1) had Zyprexa (aka Olanzapine) scheduled, took it for two days and then refused, so his doctor changed it (medication) to PRN. Record review on 01/27/2025 at 9:00am of a facility incident report made to the department showed that R1 had assaulted R2 by pushing R2 to the ground without provocation on both 01/21/2025 and 01/27/2025. This incident report noted that facility staff had made no changes to R1's negotiated service agreement (care plan) other than that R1 was 'placed on alert'. Record review on 02/07/2025 at 7:00am of a facility incident report made to the department showed that R1 had assaulted R7 by pushing R7 to the ground without provocation on 02/05/2025. This incident report noted that staff had stated 'no care plan (negotiated service agreement) changes at this time'. Record review on 02/07/2025 at 8:00am of prior facility incident reports related to R1 showed that R1 had assaulted R3 on 08/22/2024, leading to an injury (unspecified 'head injury') being noted for R3. Record review on 02/07/2025 at 8:00am of prior facility incident reports related to R1 showed that R1 had assaulted R4 on 08/23/2024 with no injury being noted. Record review on 02/07/2025 at 8:00am of prior facility incident reports related to R1 showed that R1 had assaulted R5 on 10/21/2024, leading to an injury (bruising) being noted for R5. Record review on 02/07/2025 at 8:00am of prior facility incident reports related to R1 showed that R1 had assaulted R6 on 11/26/2024, leading to an injury (hip fracture) being noted for R6. Record review on 02/12/2025 at 12:20pm of the negotiated service plan (care plan) for R1, showed that R1 was noted to have 'extensive behavioral issues' and that R1 'requires supervision, a professionally authorized behavior management plan, and/or professional consultation and intervention'. There was no indication from the record review of R1's negotiated service agreement that any such behavioral intervention had been attempted to be instated at any time since the resident's admission to the facility ( /2024). . . 02/21/2025 3 20PM FAX ia]000B/0008 ~Z.18,21125 1512lh06 State OP lklllhlngton 8/l Statement of Detliil1111cles Lloense #: 2627 Compliance Determlnoilon # saa:57 Plan of Corre0llon Gk! Harbor Memory Care compl@tlon Date Pege 4 Of4 Llcen1ee: Greenlake Management Gig Harbor. LLO 02/1212O2!i Plan/ ttestation ta ment I hereby certify that I hav& reviewed this report and have taken or will take active 11' measures to eorrect this deflclenOy. By taking this acti<ln, Gig HEPg MemotY. Qa@ l!i or Will be In compllanee with this law and I or regulation on (Date) ;·1 '.::> • ~ In addition, I WIii impiement a sy1,tem to monitor and ensure c:ontlnued compliance with th11 r~it[l'dffi; Stahl . □~;~~~~_!,~~~!~r ()B/ ~o·a/. l. :i-15'. Adml'hT!ilrlltm" \Or' t<:>epi.-ative) -} Va Statement of Deficiencies License #: 2627 Compliance Determination # 53837 Plan of Correction Gig Harbor Memory Care Completion Date Plan/Attestation Statement I hereby certify that I have reviewed this report and have taken or will take active measures to correct this deficiency. By taking this action, Gig Harbor Memory Care is or will be in compliance with this law and / or regulation on (Date)________________ . In addition, I will implement a system to monitor and ensure continued compliance with this requirement. Administrator (or Representative) Date .

This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website.

allegations. 3,4) During interview with the named resident, slight bruising was noted around the resident's left eye area. Per facility incident report this bruising was related to an injury which occurred on 12-5-23, and this was considered to be related to a fall. The . exact nature of the injury was not determined, but there was no indication that this was related to any resident to resident altercation due to the lack of any prior altercation history for the named resident or peers on the resident's unit. Per record review of the facility incident report related to this injury, there was no indication that the named resident's primary care physician's (PCP) office was notified of the injury. Per record review of photographs of the named resident provided by the complainant, the resident was noted to have the same healing bruise around their left eye on 12-24-23, but no other injury to the resident's face was apparent in this photo. Per record review of photographs taken of the named resident the following day (12-25-23), there was redness noted to the named resident's forehead which appeared to be related to either bruising or abrasion. Per interviews with several facility staff, no injury was noted to have occurred to the named resident at this time, and no incident report or notification to the resident's PCP was made. Per interview, the complainant stated they were notified of the injury by unnamed facility staff, and phone records provided by the complainant do show that the complainant did receive a call from the facility on 12-24-23 at 5:39pm, supporting the complainant's claim that facility staff did contact them regarding the injury to the resident occurring on 12-24-23. The complainant stated they had contacted the resident's Home and Community Services (HCS) case manager regarding this injury, and per interview, the HCS case manager stated they had filed a department report regarding the injury. Record review of reports made to the department did support that a report was made, but this report was not forwarded to investigative field staff. The above listed information served to support that the facility did not contact the resident's PCP as required in regard to either injury (12-5-23 and 12- 24-23). Cited as per WAC 388-78A-2640 (1a), Reporting significant change in a resident's condition. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A .