Bonaventure of Puyallup.

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION PO Box 99250, Lakewood, WA 98496 Bonaventure of South Hill LLC Bonaventure of Puyallup 14503 Meridian Avenue E Puyallup, WA 98375 RE: Bonaventure of Puyallup License # 2555 Dear Administrator: This letter addresses Compliance Determination(s) 57608 (Completion Date 05/29/2025) and 43860 (Completion Date 10/31/2024). The Department completed a follow-up inspection of your Assisted Living Facility on 05/29/2025 and found no deficiencies. Your facility meets the Assisted Living Facility licensing requirements. The Department found that deficiencies for the following licensing laws and regulations were corrected: WAC 388-78A-2600-2-i, WAC 388-78A-2640-1-c The Department staff who did the on-site verification: Carol Gijima, Community Compaint Investigator (NCI) If you have any questions, please contact me at (253)442-3013. Sincerely, Manfay Chan, Allied Health Field Manager Region 3, Unit D Residential Care Services This document was prepared by Residential Care Services for the Locator website. Residential Care Services Investigation Summary Report Provider/Facility: Bonaventure of Puyallup Provider Type: Assisted Living Facility License/Cert.#: 2555 Intake ID: 129908 Compliance Determination #: 43860 Region/Unit #: RCS Region 3 / Unit D Investigator: Carol Gijima Investigation Date(s): 07/09/2024 through 10/31/2024 Complainant Contact Date(s): Allegation(s): 1. Unexpected death Investigation Methods: Sample: Total residents: Resident sample size: Closed records sample size: 2 Observations: General environment Residents in their rooms & common areas Interviews: Resident's representative - X 3 unsuccessful attempts Record Reviews: Resident Characteristic Roster List of discharged residents Resident assessments and negotiated service agreements including discharged Staff Staff progress notes Incident log / reports Investigation Summary: 1. Per record review, interviews with residents' representatives, collateral contacts, and staff, facility failed to implement policies that addressed resident safety, and failed to notify representative of death. Failed facility practice identified. See Statement of Deficiency dated 10/31/2024. 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. Residential Care Services Investigation Summary Report Provider/Facility: Bonaventure of Puyallup Provider Type: Assisted Living Facility License/Cert.#: 2555 Intake ID: 134874 Compliance Determination #: 43860 Region/Unit #: RCS Region 3 / Unit D Investigator: Carol Gijima Investigation Date(s): 07/09/2024 through 10/31/2024 Complainant Contact Date(s): Allegation(s): 1. Unexpected death Investigation Methods: Sample: Total residents: Resident sample size: Closed records sample size: 2 Observations: General environment Residents in their rooms & common areas Interviews: Resident's representative Staff Record Reviews: Resident Characteristic Roster List of discharged residents Resident assessments and negotiated service agreements including discharged Staff Staff progress notes Incident log / reports Provider notes Investigation Summary: 1. Per record review, interviews with residents' representatives, collateral contacts, and staff, facility failed to notify representative of death. Failed facility practice identified. See Statement of Deficiency dated 10/31/2024. 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. Statement of Deficiencies License #: 2555 Compliance Determination # 43860 Plan of Correction Bonaventure of Puyallup Completion Date Page 2 of 5 Licensee: Bonaventure of South Hill LLC 10/31/2024 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: (i) To supervise and monitor residents, including accounting for residents who leave the premises; This requirement was not met as evidenced by: Based on records review and interviews, the Assisted Living Facility (ALF) failed to implement policies and procedures to account for residents and their safety. This failure resulted in 1 of 2 sample residents (Resident 1 [R1]) not getting care timely, resulting in R1 passing away. Findings included… There was no policy to review relating to supervision or accounting for residents leaving the facility. There was no meal roster to review. There was no progress notes provided to review. Record review of the incident report showed that R1’s son had called the facility inquiring about the whereabouts of R1. Report stated that the caregiver did not return with information regarding R1’s where abouts. Around 10:20pm, R1’s son called the facility again as they were concerned and had not heard from R1, and when staff went to R1’s room they found him without vitals, and cardiopulmonary resuscitation (CPR), an emergency procedure performed when the heart stops, couldn’t be performed as R1 was stiff. Record review of R1’s negotiated service agreement dated 11/30/2023 did not address safety checks to ensure R1’s wellbeing or how to account for his absence from the facility. During an interview on 07/09/2024 at 9:40am, Collateral Contact was asked how often they checked on residents. Collateral Contact stated that they didn’t before R1’s incident. Collateral Contact stated that before R1’s death, there was no system to account for residents. Collateral Contact stated that “nobody checked on him when he didn’t show up for dinner.” This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2555 Compliance Determination # 43860 Plan of Correction Bonaventure of Puyallup Completion Date Page 3 of 5 Licensee: Bonaventure of South Hill LLC 10/31/2024 During an interview on 07/09/2024 at 10:40am, Staff A, Administrator, was asked how the facility ensures that all residents were checked on and accounted for to ensure that they were safe. Staff A stated that they didn’t do checks unless it was care planned. When asked when it would be a concern for a resident not seen for an extended period, Staff A stated that R1 was “super independent…was gone all day…still driving.” When asked who last saw R1, Staff A stated that the therapist had seen R1 between 1:00pm-4:30pm. Staff A asked who had last seen R1 and when since the therapist had rescinded that statement on 05/14/2024. Staff A did not provide an answer. When asked if staff went into R1’s room to check on him after R1’s family had been calling multiple times and R1 had not signed out, Staff A stated that staff did not report back on R1’s check status. During an interview on 10/18/2024 at 1:23pm, Staff B, Registered Nurse, was asked what their procedures were on checking on residents. Staff B stated that they did not conduct safety checks unless it was care planned. When asked about R1, Staff B stated that it was not unusual not to see R1. Staff B stated that R1 was still able to drive. When asked at what point they would be concerned with resident’s absence or if resident was alive, especially for an extended period, Staff B stated that “we would get worried if he (R1) wasn’t driving and at home.” During an interview on 10/29/2024 at 10:45am, Staff C, Health and Wellness Director, was asked how the facility ensured the safety and wellbeing of residents, Staff C stated that they checked residents at mealtimes, that they have a meal roster and have “eyes on assisted living residents for each meal.” When asked for a copy of the meal roster showing that staff checked on R1 for meals, Staff C stated that they only kept those records for a month. Staff C stated they had no policy on safety checks for residents and it depended on their needs. When asked how staff would know if a resident was alive or not especially for residents who were more independent than others, Staff C stated, “good question.” Staff C was asked if anyone had seen R1 for any meals, Staff C stated that they were not sure. When asked if any staff member had inquired about R1’s whereabouts, and why he was not at dinner, Staff C stated, “no one questioned”. When asked who last saw R1 and when, Staff C stated that they were not sure, that they would have to check the incident report and get back to investigator. As of the writing of this statement of deficiency on 10/31/2024, Staff C had not contacted complaint investigator. During an interview on 10/29/2024 at 12:18pm, Resident 1’s Representative (RR1) stated that they were concerned about R1 since he had not answered any of their calls or text messages which was not like him. RR1 stated that the family started calling the facility around 10:00am and were informed that R1 was out of the building. When they had not heard from R1 by late afternoon, RR1 stated they called the facility around 3:30pm asking for someone to check on R1. RR1 stated that the facility informed them that they would send someone to check on R1. RR1 stated they had no response from R1 and called the facility around 5:30pm dinner time and were told that they sent staff to check on R1, and that R1 was not in his apartment. RR1 stated that staff did not check on R1 otherwise they would have found him in the room earlier as R1 had not left his apartment. RR1 stated family drove to facility and found upon arrival that R1 had passed. RR1 stated it was traumatizing seeing an ambulance at the facility entrance This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2555 Compliance Determination # 43860 Plan of Correction Bonaventure of Puyallup Completion Date Page 4 of 5 Licensee: Bonaventure of South Hill LLC 10/31/2024 that “…heart dropped and had a gut feeling that the ambulance was for him (R1)”. RR1 stated that the medical team could not perform CPR as R1 was too stiff, “he had been gone for a long time and no one knew…, no one actually checked on him (R1).” During an interview on 10/29/2024 at 2:18pm, Resident 1’s Representative (RR3) stated that the facility failed and “dropped the ball” when it came to his father. RR3 stated he started calling the facility around 10:00am inquiring about resident as it was unusual for him to not respond to phone calls or text messages. RR3 stated that the facility was supposed to check on resident at least for a couple of meals to ensure wellbeing, and did not believe they checked on him. Otherwise, they would have found him in his room sooner and probably would have received help. 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, Bonaventure of Puyallup 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 WAC 388-78A-2640 Reporting significant change in a resident's condition. (1) The assisted living facility must consult with the resident's representative, the resident's physician, and other individual(s) designated by the resident as soon as possible whenever: (c) The resident dies. This requirement was not met as evidenced by: Based in record review, the Assisted Living Facility (ALF) failed to notify representatives of the passing of 2 of 2 sample residents (Resident 1 & 2 [R1 & 2]). This failure resulted in emotional distress, complicating the grieving process. Findings included… Record review of the ALF’s investigations showed that family was not notified of R1 & R2’s passing. There was no progress notes provided to review for both residents. A witness statement from staff dated 06/15/2024 showed that they told RR2 that they This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2555 Compliance Determination # 43860 Plan of Correction Bonaventure of Puyallup Completion Date Page 5 of 5 Licensee: Bonaventure of South Hill LLC 10/31/2024 were not “able to get any O2 (oxygen levels) or BP readings (blood pressure). The witness statement stated that RR2 asked them to explain what that meant, and staff wrote “I did my best to explain that he may have passed between checks.” During an interview on 07/09/2024 at 10:40am, Staff A, Administrator, stated that R1’s family found out about R1’s death upon arrival to facility. Staff A did not provide an answer when asked why R1’s family was not called immediately since they had been calling throughout the day with concerns about his wellbeing. Staff A stated that R2’s Representative (RR2) was upset because staff did not state that R2 had passed away. Staff A stated that staff panicked and informed RR2 that they couldn’t obtain vitals. During an interview on 10/17/2024 at 9:08am RR2 stated that they received a call around 6:00am stating that they couldn’t get vitals from R2. RR2 stated that they informed the staff that they were on their way to the facility, and upon arrival found R2 deceased. RR2 stated they were distraught as they had asked the staff if R2 had passed away and staff couldn’t tell them. RR2 stated that they thought R2 was just struggling with his vitals as he had been having problems days prior. During an interview on 10/29/2024 at 12:18pm, Resident 1’s Representative RR1 stated that since there had not been able to contact R1 the entire day, they decided to go to the ALF. RR1 stated that when family arrived at the ALF, they saw an ambulance in the driveway, and they instantly knew that something had happened with R1. RR1 stated that the facility didn’t not notify them that R1 had died, and they had to find out when they arrived at facility. 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, Bonaventure of Puyallup 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.

—: WA DSHS report: Investigations (01/2025)

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES Aging and Long-Term Support Administration PO Box 45600, Olympia, WA 98504-5600 April 3, 2024 ELECTRONIC-FACSIMILE Administrator Bonaventure of Puyallup 14503 Meridian Avenue E Puyallup, WA 98375 Assisted Living Facility License #2555 Licensee: Bonaventure of South Hill LLC IMPOSITION OF CIVIL FINE Dear Administrator: On March 28, 2024, the Department of Social and Health Services (DSHS), Residential Care Services completed a follow-up visit at your facility. This letter constitutes formal notice of a civil fine on the license for your assisted living facility, also known as Bonaventure of Puyallup, located at 14503 Meridian Avenue E, Puyallup, by the State of Washington, Department of Social and Health Services. These actions are taken under the authority granted pursuant to Laws of 1998, Chapter 272 and RCW 18.20.190. The civil fine on the license is based on the following violation of the RCW and/or WAC as described in the attached Statement of Deficiencies (SOD) report dated March 28, 2024. Civil Fine WAC 388-78A-2484 (1)(2) Tuberculosis—Two step skin testing. $300.00 The licensee failed to ensure four staff had an initial tuberculosis (a communicable disease, TB) skin test within three day of employment and a second skin test done one to three weeks after the first one. This failure placed all residents, staff, and visitors at risk of TB infection. This is an uncorrected deficiency previously cited on November 14, 2023. NOTE: This is the violation, which resulted in the fine; see the attached Statement of Deficiencies for any additional violations. Administrator Bonaventure of Puyallup License #2555 April 3, 2024 Page 2 Attestation (Plan of Correction): Return the enclosed SOD within 10 calendar days with the following: • The date you have or will have each deficiency corrected; • A signature and date attesting that you are taking actions to correct and maintain correction for each cited deficiency. Return the signed and dated SOD to: Manfay Chan, Field Manager Region 3, Unit D 9501 Lakewood Dr SW Suite E Lakewood, WA 98499 Phone: (253) 442-3013/ Fax: (253) 589-7240 rcsregion3email@dshs.wa.gov Appeal Rights: You have two appeal rights: Informal Dispute Resolution (IDR) and an Administrative Hearing. Each has a different request timeline. Informal Dispute Resolution [RCW 18.20.195] You have an opportunity to challenge the deficiencies and/or enforcement actions through the state's IDR process. All IDR requests must be in writing and include: • The deficiencies you are disputing; and • The method of review you prefer (face-to-face, telephone conference or documentation review). The written request must be received by the 10th working day from receipt of this letter. During the IDR process, you will have the opportunity to present written and/or oral evidence to dispute the deficiencies. Send your written request to: Informal Dispute Resolution Program Manager Residential Care Services PO Box 45600 Olympia, Washington 98504-5600 Administrator Bonaventure of Puyallup License #2555 April 3, 2024 Page 3 Formal Administrative Hearing You may contest the civil fine by requesting a formal administrative hearing to challenge the deficiency, which resulted in the civil fine. All hearing requests must be in writing and include: • A copy of this letter; and • A copy of the Statement of Deficiencies. The written request must be received within twenty-eight (28) calendar days of receipt of this letter. Send your written request to: Office of Administrative Hearings PO Box 42489 Olympia, Washington 98504-2489 Payment: If you do not request a formal administrative hearing, the civil fine is due to the Office of Financial Recovery twenty-eight (28) calendar days after receipt of this letter. Mail a check for $300.00 payable to the ‘Department of Social and Health Services’, and if you have or have had a Medicaid resident(s), please include your ProviderOne ID Number # on the check, to: DSHS Office of Financial Recovery PO Box 9501 Olympia, WA 98507-9501 (360) 664-5919 / FAX: (360) 664-8401 OFRMMISVendor@dshs.wa.gov If the Office of Financial Recovery has not received your payment within twenty-eight (28) days after receipt of this letter, interest will begin to accrue immediately on the balance, at the rate of one percent per month. If you do not submit a hearing request or make payment within twenty-eight (28) days, the balance due will be recovered. Administrator Bonaventure of Puyallup License #2555 April 3, 2024 Page 4 If you have any questions, please contact Manfay Chan, Field Manager, at (253) 442-3013. Sincerely, Matt Hauser Compliance Specialist Residential Care Services Enclosure cc: Field Manager, Region 3, Unit D RCS Regional Administrator, Region 3 HCS Regional Administrator, Region 3 DDA Regional Administrator, Region 3 WA LTC Ombuds Office of Financial Recovery, Vendor Program Unit HQ Central Files DRW JB

TThhiiss ddooccuummeenntt w(cid:449)a(cid:258)s(cid:400) p(cid:393)r(cid:396)e(cid:286)p(cid:393)a(cid:258)r(cid:396)e(cid:286)d(cid:282) b(cid:271)y(cid:455) R(cid:90)e(cid:286)s(cid:400)i(cid:349)d(cid:282)e(cid:286)n(cid:374)t(cid:410)i(cid:349)a(cid:258)l(cid:367) C(cid:18)a(cid:258)r(cid:396)e(cid:286) S(cid:94)e(cid:286)r(cid:396)v(cid:448)i(cid:349)c(cid:272)e(cid:286)s(cid:400) f(cid:296)o(cid:381)r(cid:396) t(cid:410)h(cid:346)e(cid:286) L(cid:62)o(cid:381)c(cid:272)a(cid:258)t(cid:410)o(cid:381)r(cid:396) w(cid:449)e(cid:286)b(cid:271)s(cid:400)i(cid:349)t(cid:410)e(cid:286).(cid:856) TThhiiss ddooccuummeenntt w(cid:449)a(cid:258)s(cid:400) p(cid:393)r(cid:396)e(cid:286)p(cid:393)a(cid:258)r(cid:396)e(cid:286)d(cid:282) b(cid:271)y(cid:455) R(cid:90)e(cid:286)s(cid:400)i(cid:349)d(cid:282)e(cid:286)n(cid:374)t(cid:410)i(cid:349)a(cid:258)l(cid:367) C(cid:18)a(cid:258)r(cid:396)e(cid:286) S(cid:94)e(cid:286)r(cid:396)v(cid:448)i(cid:349)c(cid:272)e(cid:286)s(cid:400) f(cid:296)o(cid:381)r(cid:396) t(cid:410)h(cid:346)e(cid:286) L(cid:62)o(cid:381)c(cid:272)a(cid:258)t(cid:410)o(cid:381)r(cid:396) w(cid:449)e(cid:286)b(cid:271)s(cid:400)i(cid:349)t(cid:410)e(cid:286).(cid:856) TThhiiss ddooccuummeenntt w(cid:449)a(cid:258)s(cid:400) p(cid:393)r(cid:396)e(cid:286)p(cid:393)a(cid:258)r(cid:396)e(cid:286)d(cid:282) b(cid:271)y(cid:455) R(cid:90)e(cid:286)s(cid:400)i(cid:349)d(cid:282)e(cid:286)n(cid:374)t(cid:410)i(cid:349)a(cid:258)l(cid:367) C(cid:18)a(cid:258)r(cid:396)e(cid:286) S(cid:94)e(cid:286)r(cid:396)v(cid:448)i(cid:349)c(cid:272)e(cid:286)s(cid:400) f(cid:296)o(cid:381)r(cid:396) t(cid:410)h(cid:346)e(cid:286) L(cid:62)o(cid:381)c(cid:272)a(cid:258)t(cid:410)o(cid:381)r(cid:396) w(cid:449)e(cid:286)b(cid:271)s(cid:400)i(cid:349)t(cid:410)e(cid:286).(cid:856) TThhiiss ddooccuummeenntt w(cid:449)a(cid:258)s(cid:400) p(cid:393)r(cid:396)e(cid:286)p(cid:393)a(cid:258)r(cid:396)e(cid:286)d(cid:282) b(cid:271)y(cid:455) R(cid:90)e(cid:286)s(cid:400)i(cid:349)d(cid:282)e(cid:286)n(cid:374)t(cid:410)i(cid:349)a(cid:258)l(cid:367) C(cid:18)a(cid:258)r(cid:396)e(cid:286) S(cid:94)e(cid:286)r(cid:396)v(cid:448)i(cid:349)c(cid:272)e(cid:286)s(cid:400) f(cid:296)o(cid:381)r(cid:396) t(cid:410)h(cid:346)e(cid:286) L(cid:62)o(cid:381)c(cid:272)a(cid:258)t(cid:410)o(cid:381)r(cid:396) w(cid:449)e(cid:286)b(cid:271)s(cid:400)i(cid:349)t(cid:410)e(cid:286).(cid:856) Statement of Deficiencies License #: 2555 Compliance Determination # 30372 Plan of Correction Bonaventure of Puyallup Completion Date Page 2 of 6 Licensee: Bonaventure of South Hill LLC 11/14/2023 PO Box 99250 Lakewood, WA 98496 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. Residential Care Services Date 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-2620 Pets. If an assisted living facility allows pets to live on the premises, the assisted living facility must: (2) Ensure animals living on the assisted living facility premises: (a) Have regular examinations and immunizations, appropriate for the species, by a veterinarian licensed in Washington state; (b) Are certified by a veterinarian to be free of diseases transmittable to humans; This requirement was not met as evidenced by: Based on record reviews and interview, the Assisted Living Facility (ALF) failed to ensure 6 of 9 residents’ sampled pets (Resident 1’s pet, Resident 2’s pet, Resident 3’s pet, Resident 4’s pet, Resident 5’s pet, and Resident 6’s pet) living in the ALF had regular examinations and immunizations by a licensed veterinarian. This placed all residents at risk of diseases transmittable by animals to humans. Findings included… Record review of the ALF’s “Pet Policy ADM 1-12” revised date 07/2011 showed that "Pets must be properly vaccinated and free from disease and fleas. A record of all immunizations needs to be kept in the resident's apartment and in the resident administrative file.” Resident 1 (R1) Record review of the ALF’s “Pet Binder” showed there was no documentation of R1’s pet on file to review. TThhiiss ddooccuummeenntt w(cid:449)a(cid:258)s(cid:400) p(cid:393)r(cid:396)e(cid:286)p(cid:393)a(cid:258)r(cid:396)e(cid:286)d(cid:282) b(cid:271)y(cid:455) R(cid:90)e(cid:286)s(cid:400)i(cid:349)d(cid:282)e(cid:286)n(cid:374)t(cid:410)i(cid:349)a(cid:258)l(cid:367) C(cid:18)a(cid:258)r(cid:396)e(cid:286) S(cid:94)e(cid:286)r(cid:396)v(cid:448)i(cid:349)c(cid:272)e(cid:286)s(cid:400) f(cid:296)o(cid:381)r(cid:396) t(cid:410)h(cid:346)e(cid:286) L(cid:62)o(cid:381)c(cid:272)a(cid:258)t(cid:410)o(cid:381)r(cid:396) w(cid:449)e(cid:286)b(cid:271)s(cid:400)i(cid:349)t(cid:410)e(cid:286).(cid:856) Statement of Deficiencies License #: 2555 Compliance Determination # 30372 Plan of Correction Bonaventure of Puyallup Completion Date Page 3 of 6 Licensee: Bonaventure of South Hill LLC 11/14/2023 Resident 2 (R2) Record review of the ALF’s “Pet Binder” showed R2's pet was last seen for an examination on 09/03/2015. The record showed R2’s pet had a rabies vaccination that expired 08/13/2016. Resident 3 (R3) Record review of the ALF’s “Pet Binder” showed R3's pet was last seen for an examination on 05/09/2019. The record showed R3’s pet had a rabies vaccination that expired 05/09/2022. Resident 4 (R4) Record review of the ALF’s “Pet Binder” showed there was no documentation of R4’s pet on file to review. Resident 5 (R5) Record review of the ALF’s “Pet Binder” showed there was no documentation of R5’s pet on file to review. Resident 6 (R6) Record review of the ALF’s “Pet Binder” showed there was no documentation of R6’s pet on file to review. During an interview on 10/05/2023 at 2:00 pm, Staff A, Executive Director, said that the “Pet List for AL” coincides with the records kept in the ALF’s “Pet Binder.” 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, Bonaventure of Puyallup 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 WAC 388-78A-2484 Tuberculosis Two step skin testing. Unless the staff person meets the requirement for having no skin testing or only one test, the assisted living facility choosing to do skin testing, must ensure that each staff person has the TThhiiss ddooccuummeenntt w(cid:449)a(cid:258)s(cid:400) p(cid:393)r(cid:396)e(cid:286)p(cid:393)a(cid:258)r(cid:396)e(cid:286)d(cid:282) b(cid:271)y(cid:455) R(cid:90)e(cid:286)s(cid:400)i(cid:349)d(cid:282)e(cid:286)n(cid:374)t(cid:410)i(cid:349)a(cid:258)l(cid:367) C(cid:18)a(cid:258)r(cid:396)e(cid:286) S(cid:94)e(cid:286)r(cid:396)v(cid:448)i(cid:349)c(cid:272)e(cid:286)s(cid:400) f(cid:296)o(cid:381)r(cid:396) t(cid:410)h(cid:346)e(cid:286) L(cid:62)o(cid:381)c(cid:272)a(cid:258)t(cid:410)o(cid:381)r(cid:396) w(cid:449)e(cid:286)b(cid:271)s(cid:400)i(cid:349)t(cid:410)e(cid:286).(cid:856) Statement of Deficiencies License #: 2555 Compliance Determination # 30372 Plan of Correction Bonaventure of Puyallup Completion Date Page 4 of 6 Licensee: Bonaventure of South Hill LLC 11/14/2023 following two-step skin testing: (1) An initial skin test within three days of employment; and (2) A second test done one to three weeks after the first test. This requirement was not met as evidenced by: Based on interviews and record reviews, the Assisted Living Facility (ALF) failed to develop and implement a system to ensure 3 of 6 sampled staff (Staff B, C, and F) had an initial tuberculosis (a communicable disease, TB) skin test within three days of employment and a second skin test done one to three weeks after the first one. This failure placed all ALF residents at risk of TB infection. Findings included… Staff B Record review showed Staff B, Home Care Aide (HCA), was hired by the ALF on 08/12/2023 as a caregiver. Staff B personnel file included one TB test dated 10/03/2023, more than one month after the date of hire. A second TB test had not been done. Staff C Record review showed Staff C, Home Care Aide (HCA), was hired by the ALF on 11/23/2022 as a caregiver. Staff C personnel file included one TB test dated 10/03/2023, more than 10 months after the date of hire. A second TB test had not been done. Staff F Record review showed Staff F, Home Care Aide (HCA), was hired by the ALF on 12/05/2020 as a caregiver. Staff F’s personnel file included one TB test dated 10/03/2023, more than 2 years and 10 months after the date of hire. A second TB test had not been done. On 10/05/2023 at 9:28 am in an interview, Staff A, Executive Director (ED) said the person in charge of personnel documents which used to assist no longer works with the ED. Staff A said there were no additional documents for TB tests. Plan/Attestation Statement TThhiiss ddooccuummeenntt w(cid:449)a(cid:258)s(cid:400) p(cid:393)r(cid:396)e(cid:286)p(cid:393)a(cid:258)r(cid:396)e(cid:286)d(cid:282) b(cid:271)y(cid:455) R(cid:90)e(cid:286)s(cid:400)i(cid:349)d(cid:282)e(cid:286)n(cid:374)t(cid:410)i(cid:349)a(cid:258)l(cid:367) C(cid:18)a(cid:258)r(cid:396)e(cid:286) S(cid:94)e(cid:286)r(cid:396)v(cid:448)i(cid:349)c(cid:272)e(cid:286)s(cid:400) f(cid:296)o(cid:381)r(cid:396) t(cid:410)h(cid:346)e(cid:286) L(cid:62)o(cid:381)c(cid:272)a(cid:258)t(cid:410)o(cid:381)r(cid:396) w(cid:449)e(cid:286)b(cid:271)s(cid:400)i(cid:349)t(cid:410)e(cid:286).(cid:856) Statement of Deficiencies License #: 2555 Compliance Determination # 30372 Plan of Correction Bonaventure of Puyallup Completion Date Page 5 of 6 Licensee: Bonaventure of South Hill LLC 11/14/2023 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, Bonaventure of Puyallup 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 WAC 388-78A-24642 Background checks National fingerprint background check. (1) Administrators and all caregivers who are hired after January 7, 2012 and are not disqualified by the Washington state name and date of birth background check, must complete a national fingerprint background check and follow department procedures. This requirement was not met as evidenced by: Based on interviews and record reviews the Assisted Living Facility (ALF) failed to ensure a department national fingerprint background check (BGC) was completed for 4 of 6 sampled staff (Staff C, D, E, and F). This failure placed residents at risk of having care and services provided by staff with a disqualifying crime. Findings included… Review of personnel records revealed Staff C, Caregiver, was hired on 11/23/2022. A department name and date of birth background check result dated 11/23/2022 was in the personnel file. There was no record of the final fingerprint background check provided or in the file. Review of personnel records revealed Staff D, Caregiver, was hired on 05/29/2023. A department name and date of birth background check result dated 05/18/2023 was in the personnel file. There was no record of the final fingerprint background check provided or in the file. Review of personnel records revealed Staff E, Caregiver, was hired on 01/17/2022. A department name and date of birth background check result dated 02/09/2022 was in the personnel file. There was no record of the final fingerprint background check provided or in the file. Review of personnel records revealed Staff F, Caregiver, was hired on 12/05/2020. A department name and date of birth background check result dated 01/12/2021 was in the personnel file. There was no record of the final fingerprint background check provided or TThhiiss ddooccuummeenntt w(cid:449)a(cid:258)s(cid:400) p(cid:393)r(cid:396)e(cid:286)p(cid:393)a(cid:258)r(cid:396)e(cid:286)d(cid:282) b(cid:271)y(cid:455) R(cid:90)e(cid:286)s(cid:400)i(cid:349)d(cid:282)e(cid:286)n(cid:374)t(cid:410)i(cid:349)a(cid:258)l(cid:367) C(cid:18)a(cid:258)r(cid:396)e(cid:286) S(cid:94)e(cid:286)r(cid:396)v(cid:448)i(cid:349)c(cid:272)e(cid:286)s(cid:400) f(cid:296)o(cid:381)r(cid:396) t(cid:410)h(cid:346)e(cid:286) L(cid:62)o(cid:381)c(cid:272)a(cid:258)t(cid:410)o(cid:381)r(cid:396) w(cid:449)e(cid:286)b(cid:271)s(cid:400)i(cid:349)t(cid:410)e(cid:286).(cid:856) Statement of Deficiencies License #: 2555 Compliance Determination # 30372 Plan of Correction Bonaventure of Puyallup Completion Date Page 6 of 6 Licensee: Bonaventure of South Hill LLC 11/14/2023 located in the file. On 10/04/2023 at 10:00 am during an interview, Staff A, Executive Director said Staff C, D, E and F’s fingerprint background check results were not in personnel files. On 10/05/2023 at 09:28 am second request for complete fingerprint background checks was requested. In an interview at 09:28 am Staff A said there were no additional documents for the final fingerprint background checks. 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, Bonaventure of Puyallup 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 TThhiiss ddooccuummeenntt w(cid:449)a(cid:258)s(cid:400) p(cid:393)r(cid:396)e(cid:286)p(cid:393)a(cid:258)r(cid:396)e(cid:286)d(cid:282) b(cid:271)y(cid:455) R(cid:90)e(cid:286)s(cid:400)i(cid:349)d(cid:282)e(cid:286)n(cid:374)t(cid:410)i(cid:349)a(cid:258)l(cid:367) C(cid:18)a(cid:258)r(cid:396)e(cid:286) S(cid:94)e(cid:286)r(cid:396)v(cid:448)i(cid:349)c(cid:272)e(cid:286)s(cid:400) f(cid:296)o(cid:381)r(cid:396) t(cid:410)h(cid:346)e(cid:286) L(cid:62)o(cid:381)c(cid:272)a(cid:258)t(cid:410)o(cid:381)r(cid:396) w(cid:449)e(cid:286)b(cid:271)s(cid:400)i(cid:349)t(cid:410)e(cid:286).(cid:856) Bonaventure of Puyallup # 2555 11/14/2023 Page 2 of 3 Lakewood, WA 98496 • Complete correction(s) within 45 days, or sooner if directed by the Department, after review of your proposed correction dates. • Have your plan approved by the Department. Consultation(s): In addition, the Department provided consultation on the following deficiency or deficiencies not listed on the enclosed report. WAC 388-78A-2305 Food sanitation. The assisted living facility must: (1) Manage food, and maintain any on-site food service facilities in compliance with chapter 246-215 WAC, Food service; The Assisted Living Facility (ALF) failed to maintain temperature control when delivering meals to resident rooms. On 10/05/2023 at 8:45 am, a department licensor observed an open four-wheeled cart with three breakfast meals on plates covered by clear plastic, sitting on the 2nd floor of the ALF. An observation on 10/05/2023 at 8:50 am showed an open four-wheeled cart with two plates of breakfast food covered by clear plastic, and a medication cart with one plate of food covered by a clear plastic lid, sitting on the 3rd floor of the ALF. Over a 10-minute span, not all the trays were delivered on the 3rd floor. Licensors provided consultation to Staff J, Dining Services Manager, and Staff A, Executive Director, regarding food temperature control for delivered meals. Staff J stated they will look into obtaining temperature-controlled delivery carts for the ALF. WAC 388-78A-2305 Food sanitation. The assisted living facility must: (2) Ensure employees working as food service workers obtain a food worker card according to chapter 246-217 WAC; and The Assisted Living Facility (ALF) failed to ensure 2 of 13 sampled staff (Staff G, Server, and Staff H, Server) had current food worker cards. Before the full inspection was completed, the ALF provided the department with food worker cards for Staff G and Staff H. You Are Not: • Required to submit a plan of correction for the consultation deficiency or deficiencies stated in this letter and not listed on the enclosed report. You May: • Contact me for clarification of the deficiency or deficiencies found. In Addition, You May: • Request an Informal Dispute Resolution (IDR) review within 10 working days after you receive this letter. Your IDR request must include: o What specific deficiency or deficiencies you disagree with; TThhiiss ddooccuummeenntt w(cid:449)a(cid:258)s(cid:400) p(cid:393)r(cid:396)e(cid:286)p(cid:393)a(cid:258)r(cid:396)e(cid:286)d(cid:282) b(cid:271)y(cid:455) R(cid:90)e(cid:286)s(cid:400)i(cid:349)d(cid:282)e(cid:286)n(cid:374)t(cid:410)i(cid:349)a(cid:258)l(cid:367) C(cid:18)a(cid:258)r(cid:396)e(cid:286) S(cid:94)e(cid:286)r(cid:396)v(cid:448)i(cid:349)c(cid:272)e(cid:286)s(cid:400) f(cid:296)o(cid:381)r(cid:396) t(cid:410)h(cid:346)e(cid:286) L(cid:62)o(cid:381)c(cid:272)a(cid:258)t(cid:410)o(cid:381)r(cid:396) w(cid:449)e(cid:286)b(cid:271)s(cid:400)i(cid:349)t(cid:410)e(cid:286).(cid:856) Bonaventure of Puyallup # 2555 11/14/2023 Page 3 of 3 o Why you disagree with each deficiency; and o Whether you want an IDR to occur in-person, by telephone or as a paper review. o Send your request to: IDR Program Manager Department of Social and Health Services Aging and Long-Term Support Administration Residential Care Services PO Box 45600 Olympia, WA 98504-5600 If You Have Any Questions: • Please contact me at (253)442-3013. Sincerely, Manfay Chan, Field Manager Region 3, Unit D Residential Care Services Enclosure TThhiiss ddooccuummeenntt w(cid:449)a(cid:258)s(cid:400) p(cid:393)r(cid:396)e(cid:286)p(cid:393)a(cid:258)r(cid:396)e(cid:286)d(cid:282) b(cid:271)y(cid:455) R(cid:90)e(cid:286)s(cid:400)i(cid:349)d(cid:282)e(cid:286)n(cid:374)t(cid:410)i(cid:349)a(cid:258)l(cid:367) C(cid:18)a(cid:258)r(cid:396)e(cid:286) S(cid:94)e(cid:286)r(cid:396)v(cid:448)i(cid:349)c(cid:272)e(cid:286)s(cid:400) f(cid:296)o(cid:381)r(cid:396) t(cid:410)h(cid:346)e(cid:286) L(cid:62)o(cid:381)c(cid:272)a(cid:258)t(cid:410)o(cid:381)r(cid:396) w(cid:449)e(cid:286)b(cid:271)s(cid:400)i(cid:349)t(cid:410)e(cid:286).(cid:856)

—: WA DSHS report: Investigations (10/2023) —: WA DSHS report: Investigations (10/2023) —: WA DSHS report: Investigations (10/2023) —: WA DSHS report: Investigations (10/2023)