Gig Harbor Health: Residents Left in Wrong-Size Briefs - WA
Federal inspectors found Gig Harbor Health and Rehabilitation failed to consistently provide necessary toileting supplies for residents who depended entirely on staff for basic hygiene needs.
Resident 5 told inspectors during a July interview that the facility had run out of briefs three times since admission. When shortages occurred, it took the facility between three to five days to get the correct size back in stock.
"The staff would put a smaller size brief on them until they were able to get the right size," according to the inspection report. The resident said the smaller briefs "would feel uncomfortable and would not hold urine."
The resident described urine leaking down their leg because of the wrong-size brief.
Resident 6 experienced the opposite problem. Staff put larger briefs on this resident when supplies ran short. The oversized briefs "did not always catch all the urine and they would feel wet," the resident told inspectors in August.
Both residents have moderate cognitive impairment but can communicate their needs to staff. Resident 5 is moderately dependent on staff for toileting hygiene, while Resident 6 requires total assistance.
A certified nursing assistant confirmed the facility "did sometimes run out of briefs for the residents." When shortages occurred, "the staff would use a different sized brief," the aide told inspectors.
The central supply worker explained the ordering process required approval from multiple people before supplies could be purchased. There had been times when briefs ran out, the worker said.
When shortages happened, staff contacted their sister facility to pick up emergency supplies. The worker said briefs "could usually be obtained on the same day but there could have been a delay of up to 12 hours."
During those delays, residents remained in ill-fitting briefs that either leaked or caused discomfort.
The administrator appeared unaware of the approval bottleneck. During an August interview, the administrator said they "had not been aware they needed to approve orders for supplies every day."
The administrator acknowledged "the facility should not have been running out of briefs."
The inspection report describes residents as being "at risk for increased discomfort and a diminished quality of life" due to the supply failures.
Federal regulations require nursing homes to honor each resident's preferences, choices, values and beliefs. The facility violated this standard by failing to provide basic supplies needed for dignified toileting care.
The violation was classified as causing minimal harm or potential for actual harm to residents. Inspectors noted the deficiency affected "few" residents, though they only reviewed three residents' care for activities of daily living.
Both affected residents depend on staff for toileting assistance due to their cognitive impairment and physical limitations. Their inability to manage their own hygiene needs made them particularly vulnerable when the facility failed to maintain adequate supplies.
The shortage pattern suggests systemic problems with inventory management and supply chain oversight. Multiple staff members knew about recurring shortages, yet the administrator remained unaware of daily approval requirements that contributed to delays.
Resident 5's experience of urine leaking down their leg represents a basic failure of dignity and comfort. Resident 6's description of feeling wet from oversized briefs that failed to contain waste illustrates similar indignity.
The facility's solution of borrowing supplies from a sister facility provided only temporary relief. The 12-hour delay window meant residents could spend half a day or more in inappropriate briefs while waiting for proper supplies.
Staff acknowledged they routinely searched for briefs when supplies ran low, indicating the shortage problem was ongoing rather than isolated incidents.
The central supply worker's description of the approval process reveals bureaucratic obstacles that prevented timely restocking of essential supplies. Basic toileting needs should not require multi-level approvals that create supply gaps.
Federal inspectors completed their review on August 27, 2025, following a complaint investigation. The facility must submit a plan of correction to continue participating in Medicare and Medicaid programs.
For residents like those interviewed, the impact extends beyond physical discomfort. Being forced to wear ill-fitting briefs that leak creates embarrassment and undermines the basic dignity that federal regulations are designed to protect.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Gig Harbor Health and Rehabilitation from 2025-08-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
GIG HARBOR HEALTH AND REHABILITATION in GIG HARBOR, WA was cited for violations during a health inspection on August 27, 2025.
Resident 5 told inspectors during a July interview that the facility had run out of briefs three times since admission.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.