Cottesmore Of Life Care
COTTESMORE OF LIFE CARE in GIG HARBOR, WA — inspection on February 27, 2026.
Found 7 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Findings included .
During an interview with Resident Council on 02/25/2026 at 3:45 PM, Residents 1, 10, and 16 stated they were not aware of the location of the state survey inspections.
Observation on 02/25/2026 at 4:15 PM showed the state inspection binder was located at the front reception desk, lying on its side.
The desk height was higher than a tabletop, which made it difficult for an individual in a wheelchair to view the title located on the top of the binder.
There was no signage posted that identified that the binder was there.
During an interview on 02/25/2026 at 4:15 PM, Staff G, Receptionist, stated there was no signage posted showing where the survey binder could be located.
During an interview on 02/25/2026 at 4:18 PM, Staff A, Administrator (ADM), stated the facility previously had a sign posted but it was taken down during a remodel.
Staff A stated the lack of signage did not meet expectations.
Reference WAC 388-97-0480
Findings included .The facility Abuse, Neglect and Exploitation policies, revised October 2022, showed It is the policy of the facility that all allegations of abuse, neglect.are promptly and thoroughly investigated.
Complaints and grievances will be investigated as outlined.
The facility will ensure all residents are protected from physical and psychosocial harm during and after the investigation.In response to the allegations the facility will ensure that alleged violations are reported within 24 hours to the Administrator and other officials in accordance with State law through established procedures.
Review of the electronic health record (EHR) showed Resident 1 readmitted to the facility on [DATE] with diagnoses to include chronic kidney disease, anxiety and Parkinson's disease (movement disorder of the nervous system). Resident 1 was able to make needs known.
Review of the Resident Council meeting minutes dated 11/28/2025 showed a complaint that Resident 1 informed staff they needed a brief change.
Staff stated they would inform another Certified Nursing Assistant (CNA). Resident 1 was not attended to in a timely fashion.
Review of a grievance form dated 11/28/2025 showed, Night shift slamming doors and disruptive and night shift staff are not managing their scheduled time effectively in regard to brief changes.
The grievance was signed by Staff L, Activities Director.
Review of the facility's Documentation of Follow-Up showed all night shift nursing assistants were provided in-service education related to Leaving residents who do not have the ability to make their needs known without a brief change for multiple hours.
Review of the provided documentation did not show evidence of an interview with Residents 1 to determine if there was an outcome to the residents and if neglect had occurred or evidence of interviews with residents or staff.
During an interview on 02/25/2026 at 3:51 PM, Resident 1 stated they informed a CNA at 10 PM that they had a bowel movement (BM) and required a brief change.
The CNA turned off the call light and stated they would inform the CNA assigned to Resident 1.
The assigned CNA responded approximately 3 hours later at 1 AM.
During an interview on 02/26/2026 at 8:45 AM, Staff L, Activity Director, stated after writing the grievance they believed the incident was an allegation of neglect and reported the incident to Staff A, Administrator, who was also the Abuse Coordinator.
Staff L stated, A resident sitting in their BM for 3 hours seems like neglect to me. As a mandated reporter I was informed to report those concerns to Staff A.
During an interview on 02/26/2026 at 11:50 AM, Staff K, CNA, stated if a resident reported not having a brief change for several hours after requesting it they would assist the resident and then report it to the nurse for staff neglecting to provide care to the resident.
During an interview on 02/26/2026 at 11:52 AM, Staff H, Resident Care Manager, stated when a resident reported they did not receive timely care, the staff member should notify management and complete grievance due to the allegation of neglect.
Staff H stated three hours was an unacceptable amount of time to wait.
During an interview on 02/25/2026 at 12:54 PM, Staff A, Administrator, stated they interviewed Resident 1 and staff were provided education as a resolution to the concern.
During an interview on 02/26/2026 at 12:03 PM, Staff B, Director of Nursing Services, stated they were unaware of the situation until yesterday.
Staff B stated an investigation to include interviews, a skin assessment, social services evaluation and determining if there was an allegation of neglect should have been completed.
Staff B stated the lack of investigation did not meet their expectations.
Reference WAC 388-97-0640(6)(a)(b)
505499 02/27/2026
Cottesmore of Life Care 2909 14th Avenue Northwest Gig Harbor, WA 98335
Review of the EHR showed Resident 11 had an active focused care plan for terminal prognosis, (a medical assessment that an incurable, irreversible, or progressive disease is expected to end in death, often within six months or less) initiated on 10/07/2025, showed Resident 11 received hospice services (end of life care and services) with interventions being implemented.
Review showed hospice care services were being provided and documented per the active provider's order for hospice.
Review of the quarterly MDS dated [DATE] showed it was coded No for hospice services.
During an interview on 02/26/2026 at 12:47 PM, Staff D, MDS Coordinator (MDSC), stated Resident 11 was receiving hospice services and the 01/08/2026 quarterly MDS was coded No, and should have been coded, Yes.
Staff D stated the MDS needed to be modified.
During an interview on 02/26/2026 at 12:51 PM, Staff B, Director of Nursing Services (DNS), stated Resident 11's quarterly MDS dated [DATE] was inaccurately coded for hospice and did not meet their expectations. Resident 8
Review of the EHR showed Resident 8 admitted to the facility on [DATE] with diagnoses of dementia, stage 4 pressure ulcer (the most severe form of skin and tissue damage caused by long-term pressure), and anemia (lack of healthy red blood cells reducing oxygen supply to the body). Resident 8 was unable to communicate needs.
Review of the quarterly modification MDS dated [DATE] showed Resident 8 had a stage 4 pressure ulcer (PU).
Review of the EHR showed Resident 8 had an active provider's order dated 06/30/2025 to provide daily treatment to a stage 4 PU to the left lower back area.
Review showed the treatment was provided per the provider's order.
Review of the quarterly MDS dated [DATE] showed Resident 8 had a stage 3 PU (wound that exposed fatty tissue, not as deep as a stage 4) and not a stated 4 PU.
During an interview on 02/26/2026 at 1:14 PM, Staff E, MDSC, stated Resident 8 had a stage 4 PU; however, the quarterly MDS dated [DATE] was coded for a stage 3 PU and should have been coded for a stage 4 PU.
Staff E stated the MDS needed to be modified.
During an interview on 02/26/2026 at 1:35 PM, Staff B, DNS, stated Resident 8's quarterly MDS dated [DATE] was inaccurately coded for a stage 4 PU and this did not meet their expectations.
Reference WAC 388-97 -1000 (1)(b)(4)(a)
505499 02/27/2026
Cottesmore of Life Care 2909 14th Avenue Northwest Gig Harbor, WA 98335
505499 02/27/2026
Cottesmore of Life Care 2909 14th Avenue Northwest Gig Harbor, WA 98335
Findings included .
Review of the electronic health record (EHR) showed Resident 7 readmitted on [DATE] with diagnoses to include left foot pain, diabetes (too much sugar in the blood) and peripheral vascular disease (condition that restricts blood flow). Resident 7 was able to make needs known.
Review of Resident 7's medication list showed a provider's order dated 01/27/2026 for oxycodone (a narcotic opioid pain medication) every four hours as needed (PRN) for pain.Review of Resident 7's February 2026 MAR showed oxycodone administered 20 out of 28 days.
There was no documentation NPI was offered/provided prior to the administration of the oxycodone.
During an interview on 02/26/2026 at 10:03 AM, Staff C, Resident Care Manager, stated nursing staff should have offered ice and repositioning prior to administering the as needed pain medication.
Staff C stated the expectation was to document Resident 7's pain level and the interventions attempted and make sure the appropriate PRN medication was given for the pain level.
During an interview on 02/26/2026 at 11:58 AM, Staff B, Director of Nursing Services, stated the expectation was when an order for a PRN pain medication was entered into the EHR staff should have also indicated an area on the MAR to document that a NPI was offered and if it met the resident's needs.
Reference WAC 388-97-1060(1), -1620(2)(b)(i)(ii)
505499 02/27/2026
Cottesmore of Life Care 2909 14th Avenue Northwest Gig Harbor, WA 98335
Observation on 02/23/2026 at 10:32 AM showed Resident 6 in bed with two pill cups with
consumed both pill cups' medication during an interview.
Review of a Medication Self-Administration Review assessment, dated 11/20/2025, showed Resident 6 was assessed to be able to self-administer medicated eye drops, but not any pill medications.
Review of the care plan, initiated 07/08/2024, showed Resident 6 was assessed to be able to self-administer medicated eye drops, but not any pill medications.
During an interview on 02/27/2026 at 9:23 AM, Staff Q, Registered Nurse, stated residents were allowed to self-administer medications if they were assessed to be competent and kept them in a locked box.
Staff Q stated Resident 6 was not assessed to be able to self-administer any medications.
During an interview on 02/27/2026 at 10:51 AM, Staff B, DNS, stated residents should be assessed prior to self-administering medications and medications should not be left at bedside without this assessment.
Staff B stated Resident 6's medications at bedside did not meet expectations.
Medication Storage Observation on 02/23/2026 at 12:20 PM showed a treatment cart on Transition Care Unit (TCU) unlocked and no staff were around.
During an interview on 02/23/2026 at 12:21 PM, Staff P, Licensed Practical Nurse, stated the treatment cart should have been locked.
Observation on 02/25/2026 at 10:31 AM showed a medication cart on TCU left unlocked with no staff round.
During an interview on 02/25/2026 at 10:33 AM, Staff O, Staff Development Coordinator, stated the cart should have been locked.
During an interview on 02/25/2026 at 1:03 PM, Staff B, Director of Nursing Services, stated the treatment and medication carts should be locked at all times when not attended by licensed nurses, and having the treatment and medication cart unlocked on TCU unit did not meet expectations.
Reference WAC 388-97-1300(2), -2340
505499 02/27/2026
Cottesmore of Life Care 2909 14th Avenue Northwest Gig Harbor, WA 98335
During an interview on 02/23/2026 at 1:04 PM, Resident 94 stated they had spoken to the dietician and discussed receiving smaller portion size. Resident 94 stated they were still getting large meal portions and at times felt overwhelmed with the amount of food.
Observation on 02/24/2026 at 8:42 AM showed Resident 94's meal tray card had Regular Texture, heart health, no salt packet, fluid restriction 1500 ml.
There were no preferences listed.
Review of a Registered Dietician progress note dated 01/23/2026 showed Add small portions to meals per resident request.
Review of Resident 94's EHR showed a 01/21/2026 provider's order for Heart healthy (cardiac) diet, regular texture, thin consistency, no salt packets, small portions with meals.
During an interview on 02/24/2026 at 12:42 PM, Staff F, Dietary Manager, stated they must have missed transferring information to the resident's meal card related to the portion sizes.
Reference WAC 388-97-1140(6)
505499 02/27/2026
Cottesmore of Life Care 2909 14th Avenue Northwest Gig Harbor, WA 98335