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State records show Pierce County facility lacked ‘sanitary’ environment ahead of COVID-19 outbreak

Gibraltar Senior Living, which operates under the name Alpha Cottage LLC, is located in the Parkland area of unicorporated Pierce County, near Franklin Pierce High School.
Kari Plog
Gibraltar Senior Living, which operates under the name Alpha Cottage LLC, is located in the Parkland area of unicorporated Pierce County, near Franklin Pierce High School.

This story has been updated to include remarks from the state's long-term care ombuds. 

A long-term care facility in Pierce County was put on notice for unsanitary conditions two weeks before an employee brought COVID-19 into the building, infecting a majority of the residents living there. It was the latest in a series of similar warnings from the state that called into question the safety of residents. 

Gibraltar Senior Living houses many residents who are formerly homeless and suffering from severe mental illness.

The Parkland-area facility, which operates under the name Alpha Cottage LLC, received a letter from the Aging and Long-Term Support Administration, a division of the state Department of Social and Health Services, on March 25. The letter warned management that an unannounced inspection at the beginning of March revealed the facility didn’t meet state standards. 

Inspectors found that Gibraltar failed to “provide a sanitary and well-maintained environment” for all its residents, among other deficiencies, identifying three pages of housekeeping and maintenance issues.

“This failure placed all residents’ health and well-being at risk,” the letter states. 

A couple weeks later on April 9, a staff member at the facility tested positive for COVID-19. That triggered an outbreak, resulting in 34 positive cases among residents and staff. More than half of the 46 residents housed there at the time were eventually infected, as well as seven employees. Three out of the four residents who were hospitalized died, said Salan Weyer, who was serving as the facility administrator at the time of the outbreak. She said she did not know what happened to the fourth person who was hospitalized. 

Weyer took over ownership of Gibraltar in May, a deal she says took roughly two years to finalize with the previous owner. The license for the facility was placed in her name in January, and she’s been in charge of day-to-day operations at the facility for two years. 

Weyer doesn’t dispute the state’s findings that preceded the facility’s outbreak. She says any significant improvements were out of her hands until she assumed ownership.

“As soon as I took over I corrected all of it,” Weyer told KNKX Public Radio in an interview Thursday. “I purchased the facility as is. I didn’t have funds, until I took over, to implement the changes.”

Patricia Hunter, the state's long-term care ombuds, says addressing those issues isn't a matter of ownership. Hunter stressed it was Weyer's responsibility, as the licensed administrator, to make sure the facility complied with state law. 

“She’s responsible for implementing the policies and procedures,” Hunter said. 

A state investigation into the COVID-19 outbreak didn’t result in any fines against the facility, said DSHS spokesperson Chris Wright.

The so-called “statement of deficiency” sent by the agency in March is among more than a dozen similar letters sent to Gibraltar dating back to 2012, according to documents obtained by KNKX. The state has taken enforcement action against the facility just once in that time. 

The reports detail problems with housekeeping and staff training, as well as monitoring resident safety and administering medications. In two cases, the facility was cited for incidents involving resident injury or death.

Wright says statements of deficiency issued by his agency’s Residential Care Services are corrective in nature. They aim to give facilities the opportunity to address any identified concerns. Upon receiving a letter, a facility has 10 days to acknowledge the shortfalls and issue a plan of correction that must be acted on within 45 days.

The state didn’t follow up on the facility’s progress until last month, due to changes in site visits as a result of the pandemic.

“Gibraltar/Alpha Cottage was expected to correct those deficiencies, but Residential Care Services did not conduct the usual follow-up visit to see that they were corrected,” Wright said in a written statement. He said those visits were suspended at the beginning of the pandemic, so all of those resources could be directed to infection control efforts. “Revisits were limited to facilities with current enforcement actions and this facility did not have any.”

Wright says the only enforcement action taken against Gibraltar was in August 2019, when the facility was fined $2,000 for failing to properly monitor a resident’s well-being. Records show a resident’s blood hadn’t been monitored as required. The resident “sustained (an) abdominal and brain bleed” and was hospitalized in intensive care. Gibraltar appealed the fine, and it was rescinded in December 2019, Wright said. 

Despite a lack of punitive action from the state, records show other instances in which the long-term care facility put residents’ safety at risk over the past five years.   

In October 2015, Gibraltar was cited after a resident, who required constant supervision, went missing temporarily at the Washington State Fair in Puyallup, during an outing with a previous owner of the facility. The resident entered a public restroom unaccompanied, wandered off using a separate entrance and was returned to the facility the next day by a police officer.     

In March 2017, the facility was cited for failing to follow its own policy for monitoring and supervising residents. A resident was found dead early one morning after he had not been checked on for at least nine hours. The facility’s policy required residents to be monitored every two hours overnight. 

At the time, the resident was taking an antibiotic, which the facility had on hand but did not administer. Staff said in interviews with the state that they were trying to verify the order, after the resident’s health care provider speculated it may have been mistakenly filled with an old prescription. The resident died in the process.    

And in May 2019, during an unannounced on-site investigation, the state found a resident with facial bruises and back redness from an “unknown source.” The facility was cited for failing to conduct an investigation to rule out abuse.

No enforcement actions were taken in those incidents. Wright says citations such as these trigger further review from the state, which sometimes result in fines that are later rescinded.

Wright said the volume of deficiencies identified at Gibraltar in recent years “is probably higher than average.” But, he added, “with more than 500 Assisted Living Facilities in the state, it’s difficult to make a comparison over that long of a time period.”

The most recent findings from the spring include more than two dozen notes about unsanitary conditions at the facility during unannounced site visits March 3-5 and March 9. 

Among the observations, an inspector discovered cracked windows in some of the rooms, as well as heavily soiled window sills and doors, cracked and peeling paint, and areas of exposed sub-flooring.

Thick black dust covered surfaces in the kitchen, including exposed pipes and wires and the front of an air conditioner placed in a window facing the food preparation area. Clean dishes were stored on sticky shelves with chipping paint, and the area just outside the facility’s entryway was littered with cigarette butts, debris and garbage. Dried vomit was discovered on the floor of one resident’s room, and another resident interviewed said the rooms hadn’t been mopped “since the housekeepers left after Thanksgiving" in November 2019.

Weyer says her facility houses residents that are especially challenging to care for, given their severe mental health and medical diagnoses, including schizophrenia and dementia. That complicates matters of hygiene, she stressed. She noted her facility is “a step down from Western State,” a psychiatric hospital in Pierce County, in terms of the population it serves.

Hunter, the state ombuds, said that isn't an excuse for a lower standard of care or conditions in a facility. “This population can be challenging, but they are highly vulnerable,” Hunter said. “Their environment is a sign of dignity.”

Weyer says she took ownership of the facility because her “heart and soul” is invested in caring for the people who live there. 

“I love our residents,” she said. “I think we’ve improved so many things since I have taken over.”

Weyer says that includes repairing all the damaged windows, painting and sanitizing the kitchen, upgrading plumbing, and hiring an entirely new staff, including housekeepers.

In visits last month, state inspectors did confirm some compliance issues at Gibraltar had been resolved, Wright said. However, he added, others are still subject to an active investigation. DSHS does not comment on open investigations.  

Weyer says she believes residents are getting better care since she took over several months ago, and she’ll continue working with the state to address any issues that arise. 

“Sometimes we don’t get the fair end of the stick, especially when you’re talking about and working with residents like we have,” she said. “I think we do a good job here. I think it could be better. It’s going to be better.”

Kari Plog is an award-winning reporter covering the South Sound, including Pierce, Thurston and Kitsap counties. Before transitioning to public radio in 2018, Kari worked as a print journalist at The News Tribune in Tacoma.