Bonaventure of Lacey.

—: WA DSHS report: Investigations (01/2026)

—: WA DSHS report: Investigations (09/2025)

—: WA DSHS report: Investigations (06/2025) —: WA DSHS report: Investigations (06/2025) —: WA DSHS report: Investigations (06/2025) —: WA DSHS report: Investigations (06/2025) —: WA DSHS report: Investigations (06/2025)

Residential Care Services Investigation Summary Report Provider/Facility: Bonaventure of Lacey Provider Type: Assisted Living Facility License/Cert.#: 2036 Compliance Determination #: 33439 Intake ID: 104832 Investigator: Paul Aube Region/Unit #: RCS Region 3 / Unit E Investigation Date(s): 12/05/2023 through 12/06/2023 Complainant Contact Date(s): Allegation(s): Other: Public allegation of sexual abuse from a staff to a resident in the community, Investigation Methods: Sample: Total residents: 68 Resident sample size: 1 Closed records sample size: 1 Observations: Residents Dining Resident rooms Staff to resident interactions Resident to resident interactions Interviews: Residents Nursing staff Management Record Reviews: Resident Characteristic Roster Facility policies Incident Log Resident Progress Notes Investigation Summary: Other: Facility failed to follow policy, and complete an Occurrence Report when they became aware of an allegation of sexual abuse in the community. Facility also failed to document investigation, and investigative actions. Failed practice identified. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A This document was prepared by Residential Care Services for the Locator website.

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES Aging and Long-Term Support Administration PO Box 45600, Olympia, Washington 98504-5600 September 28, 2023 (email) Nicole Brophy-Director of Health Services Miah Rosellini-Administrator Bonaventure of Lacey 3425 Boone Rd SE Salem, OR 97317 IDR RE-SCHEDULING LETTER License #2036 Dear Administrator: This letter will confirm your request for an Informal Dispute Resolution (IDR) regarding the Statement of Deficiencies dated August 25. 2023 Based on your conversation with IDR Program staff, your IDR review meeting is now scheduled for: • Date and Time October 26, 2023 at 1:30 • Type of Review Direct/Teams You can call 1-564-999-2000 conference ID 917 381 243# or you may join the Teams meeting via computer with the link from your calendar invitation sent to you again on September 28, 2023. You indicated you are disputing the following citation(s): WAC 388-78A-2450 and WAC 388-78A-2300 You indicated the following individuals will participate and represent your facility in the IDR process: Nicole Brophy-Director of Health Services, Miah Rosellini-Administrator, Pam Gray- COO, Possible Attendee Chris Gomez-Dining Services Director Please provide additional documentation specifically related to the citation(s) you are disputing at least one week prior to the scheduled IDR date by emailing them to RCSIDR@dshs.wa.gov or by faxing them to (360) 725-3225. If you have any questions, please contact me at (360) 725-3233 or Rebecca Fueston at (360) 725-3203. Sincerely, Kim Friesz for Kim Friesz for Rebecca Fueston IDR Program Manager Residential Care Services Enclosure cc: Field Manager, Region 3 Unit E Regional Long Term Care Ombuds State Long Term Care Ombuds Field File Central Files IDR File

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES Aging and Long-Term Support Administration PO Box 45600, Olympia, Washington 98504-5600 November 28, 2023 (email) Megan Harrison- Assistant Executive Director Bonaventure of Lacey c/o 3425 Boone Rd SE Salem, OR 97317 AsstEDLCY@livebsl.com IDR RESULTS ALF License #2036 Dear Administrator: Thank you for participating in the Informal Dispute Resolution (IDR) process on October 31, 2023. This letter is a follow-up to my telephone call with Nicole Brophy about the results of the IDR. During the IDR, citations from the Statement of Deficiencies (SOD) report dated September 21, 2023 (CD 29442) were addressed. As we discussed during the IDR, the following information was considered: • All written materials presented by the assisted living facility. • All oral statements and explanations offered by the assisted living facility. • Records gathered by the RCS regional staff. In addition, I questioned RCS regional staff and RCS Nurse Delegation Subject Matter Expert to clarify facts and issues that were raised. After careful review and consideration, I have decided to make the following change to the SOD report dated September 21, 2023 (CD 29442): WAC 388-78A-2240 Non availability of medications – Edited, added that a fax was sent between 8/7-8/16. WAC 388-78A-2320 Intermittent Nursing Services-Edited, Removed language regarding signed physician orders as well as regarding diabetic care for Resident 5. WAC 388-78A-3100 Safe Storage of supplies and equipment-No Change WAC 388-78A-2660 Resident Rights-Edited, Updated deficient practice statement to clarify that resident 8 and 9’s grievances were unresolved. Based on the above, no change was made to the previously imposed enforcement action dated October 4, 2023. Next Steps: • Review the attached amended cover letter and SOD reflecting the change noted above. • Follow instructions according to the cover letter to the SOD. Note: The Length of time for completion and posting of final documents to the DSHS locator, including amended documents, will vary. If you are looking for specific information not currently posted, please contact pdd@dshs.wa.gov If you have any questions, please contact me at staci.dilg@dshs.wa.gov . Sincerely, Staci Dilg IDR Program Manager Residential Care Services Enclosure cc: Regional Administrator, Region 3 Field Service Administrator, Reg 3 Field Manager, Region 3E Regional Long Term Care Ombuds Statewide Long Term Care Ombuds Office of Financial Recovery, Vendor Program Unit Compliance Unit Nicole Brophy, NBrophy@livebsl.com Central File IDR File

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES Aging and Long-Term Support Administration PO Box 45600, Olympia, Washington 98504-5600 September 14, 2023 (email) Nicole Brophy-Director of Health Services Miah Rosellini-Administrator Bonaventure of Lacey 3425 Boone Rd SE Salem, OR 97317 IDR SCHEDULING LETTER License #2036 Dear Administrator: This letter will confirm your request for an Informal Dispute Resolution (IDR) regarding the Statement of Deficiencies dated August 25. 2023 Based on your conversation with IDR Program staff, your IDR review meeting is scheduled for: • Date and Time September 28, 2023 at 1:30 • Type of Review Direct/Teams You can call 1-564-999-2000 conference ID 917 381 243# or you may join the Teams meeting via computer with the link from your calendar invitation sent to you on September 14, 2023. You indicated you are disputing the following citation(s): WAC 388-78A-2450 and WAC 388-78A-2300 You indicated the following individuals will participate and represent your facility in the IDR process: Nicole Brophy-Director of Health Services, Miah Rosellini-Administrator, Pam Gray- COO, Possible Attendee Chris Gomez-Dining Services Director Please provide additional documentation specifically related to the citation(s) you are disputing at least one week prior to the scheduled IDR date by emailing them to RCSIDR@dshs.wa.gov or by faxing them to (360) 725-3225. If you have any questions, please contact me at (360) 725-3233 or Rebecca Fueston at (360) 725-3203. Sincerely, Kim Friesz for Kim Friesz for Rebecca Fueston IDR Program Manager Residential Care Services Enclosure cc: Field Manager, Region 3 Unit E Regional Long Term Care Ombuds State Long Term Care Ombuds Field File Central Files IDR File