Bonaventure of Puyallup.

WAC 388-78A-2600(2)(i): The facility failed to implement policies and procedures to supervise and monitor residents, including accounting for residents who leave the premises. A resident (R1) was not checked on timely and died without staff knowing his whereabouts, despite family members calling multiple times to request welfare checks. WAC 388-78A-2640(1)(c): The facility failed to notify representatives of the passing of 2 of 2 sample residents (Resident 1 and Resident 2), resulting in emotional distress and complicating the grieving process.

RCW 70.129.110: The facility failed to provide written discharge notice to a resident who was discharged after hospitalization. The notice was required to include the reason for discharge, effective date, location of transfer, and ombudsman contact information.

WAC 388-78A-2350: The facility failed to coordinate care with external health care providers and respond timely and appropriately during a medical emergency for Resident 1. Facility staff hesitated to intervene when instructed by 911 operator to move the resident from a bedside commode and position them for CPR, resulting in a delay in care and a less than pleasant death with dignity. —: The facility failed to provide care and services to Resident 1 as stated in the Negotiated Service Agreement related to toileting the resident.

WAC 388-78A-2620: The facility failed to ensure 6 of 9 sampled residents' pets had regular veterinary examinations and immunizations by a licensed Washington veterinarian. Four residents had no documentation of their pets on file, and two residents had pets with expired rabies vaccinations (expired 08/13/2016 and 05/09/2022). This placed all residents at risk of diseases transmittable by animals to humans. WAC 388-78A-2484: The facility failed to ensure 3 of 6 sampled staff (Staff B, C, and F) had an initial tuberculosis skin test within three days of employment and a second skin test one to three weeks after the first. Staff B's first test was over one month late with no second test; Staff C's first test was over 10 months late with no second test; Staff F's first test was over 2 years and 10 months late with no second test. This placed all residents at risk of TB infection. WAC 388-78A-24642: The facility failed to ensure a department national fingerprint background check was completed for 4 of 6 sampled staff (Staff C, D, E, and F) who were hired after January 7, 2012. While initial name and date of birth checks were completed, no final fingerprint background check results were on file. This placed residents at risk of care from staff with potential disqualifying crimes.

WAC 388-78A-3140: The facility failed to cooperate with the department by not providing requested resident and staff records during an investigation. Despite multiple follow-up requests via email and in-person interviews, records for residents 3 and 4 and most staff documents were never provided, hindering the department's ability to conduct a thorough and timely investigation.