Bonaventure of Vancouver.

Residential Care Services Investigation Summary Report Provider/Facility: Bonaventure of Vancouver Provider Type: Assisted Living Facility License/Cert.#: 2535 Intake ID: 192613 Compliance Determination #: 65295 Region/Unit #: RCS Region 3 / Unit E Investigator: Richard Westom Investigation Date(s): 09/09/2025 through 09/10/2025 Complainant Contact Date(s): Allegation(s): 1. Unqualified personnel. Staff with no finger prints. 2. Administrative/Personnel. Staff with no HCA. 3. Quality of care/Treatment. Residents with falls. 4. dietary services. No temp log for food. 5. Quality of life. showers not being given. Investigation Methods: Sample: Total residents: 89 Resident sample size: 3 Closed records sample size: 0 Observations: Residents Resident rooms Staff to resident interactions Medication administration Interviews: Nursing staff Record Reviews: Medical records Facility policies Investigation Summary: 1. Unqualified personnel. after interviews and record review facility failed to do TB test on 4 of 4 staff reviewed. Failed practice. 2. Administrative/Personnel. Observation of staff records show staff have HCA with in guidelines. No failed practice. 3. Quality of care/Treatment. Investigations complete, notifications done. No failed practice. 4. dietary services. Observed 30 days of food temps. no failed practice. 5. Quality of life. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written This document was prepared by Residential Care Services for the Locator website. Failed Provider Practice Not Identified / No Citation Written N/A This document was prepared by Residential Care Services for the Locator website.

This document was prepared by Residential Care Services for the Locator website. STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEAL TH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 800 NE 136th Ave Ste 200, Vancouver, WA 98684 BONAVENTURE OF VANCOUVER LLC Bonaventure of Vancouver 3425 Boone Rd SE Salem, OR 97317 RE: Bonaventure of Vancouver License# 2535 Dear Administrator: This letter addresses Compliance Determination(s) 53364 (Completion Date 02/06/2025) and 51041 (Completion Date 12/05/2024). The Department completed a follow-up inspection of your Assisted Living Facility on 02/06/2025 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-2320, WAC 388-78A-2320-1, WAC 388-78A-2320-1-a, WAC 388-78A-2320-1-b, WAC 388-78A-2320-2, WAC 388-78A-2320-2-a, WAC 388-78A-2320-2-b, WAC 388-78A-2320- 2-c, WAC 388-78A-2320-2-d, WAC 388-78A-2320-2-e, WAC 388-78A-2320-2-f, WAC 388-78A- 2320-3, WAC 388-78A-2320-3-a, WAC 388-78A-2320-3-b, WAC 388-78A-2320-3-c, WAC 388- 78A-2320-3-d, WAC 388-78A-2320-3-e, WAC 388-78A-2210-1-b, WAC 388-78A-2474-2-b, WAC 388-78A-2474-2-c, WAC 388-78A-2474-2-e, WAC 388-78A-2090, WAC 388-78A-2090-1, WAC 388-78A-2090-1-a, WAC 388-78A-2090-1-b, WAC 388-78A-2090-1-c, WAC 388-78A- 2090-2, WAC 388-78A-2090-2-a, WAC 388-78A-2090-2-b, WAC 388-78A-2090-2-c, WAC 388- 78A-2090-3, WAC 388-78A-2090-4, WAC 388-78A-2090-4-a, WAC 388-78A-2090-4-b, WAC 388-78A-2090-5, WAC 388-78A-2090-5-a, WAC 388-78A-2090-5-b, WAC 388-78A-2090-5-c, WAC 388-78A-2090-6, WAC 388-78A-2090-6-a, WAC 388-78A-2090-6-b, WAC 388-78A-2090- 6-c, WAC 388-78A-2090-6-d, WAC 388-78A-2090-6-e, WAC 388-78A-2090-7, WAC 388-78A- 2090-7-a, WAC 388-78A-2090-7-b, WAC 388-78A-2090-7-c, WAC 388-78A-2090-7-c-i, WAC 388-78A-2090-7-c-ii, WAC 388-78A-2090-7-d, WAC 388-78A-2090-8, WAC 388-78A-2090-8-a, WAC 388-78A-2090-8-b, WAC 388-78A-2090-8-b-i, WAC 388-78A-2090-8-b-ii, WAC 388-78A- 2090-9, WAC 388-78A-2090-10, WAC 388-78A-2090-11, WAC 388-78A-2090-11-a, WAC 388- 78A-2090-11-b, WAC 388-78A-2090-11-c, WAC 388-78A-2130-2, WAC 388-78A-2390, WAC 388-78A-2390-1, WAC 388-78A-2390-2, WAC 388-78A-2480-1, WAC 388-78A-2620-2-a, WAC 388-78A-2620-2-b, WAC 388-78A-2665, WAC 388-78A-2665-1, WAC 388-78A-2665-2, WAC 388-78A-2665-3, WAC 388-78A-2665-4, WAC 388-78A-2665-5, WAC 388-78A-2665-6, WAC 388-78A-2730-2-b-iii, WAC 388-78A-3140-2 This document was prepared by Residential Care Services for the Locator website. Bonaventure of Vancouver# 2535 02/06/2025 Page 2 of2 The Department staff who did the on-site verification: Kyle Gehlen, ALF Licensor - LT C Jennifer Siharath, ALF Licensor If you have any questions, please contact me at (360)746-4675. Sincerely, Clinton Fridley, Adult Family Home Nurse Fi Region 3, Unit I Residential Care Services This document was prepared by Residential Care Services for the Locator website. STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALT H SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 800 NE 136th Ave Ste 200, Vancouver, WA 98684 statement of Deficiencies License #: 2535 Compliance Determination # 51041 Plan of Correction Bonaventure of Vancouver Completion Date Page1 of21 Licensee: BONAVENTURE OF VANCOUVER LLC 12/05/2024 You are required to be in compliance at all times with all licensing laws and regulations to maintain your Assisted Living Facility license. The department completed data collection for the unannounced on-site full inspection on 12/02/2024 and 12/05/2024 of: Bonaventure of Vancouver 9317 NE 86th Street Vancouver, WA 98662 The following sample was selected for review during the unannounced on-site visit 12 of 91 current residents and 0 former residents. The department staff that inspected the Assisted Living Facility: Kyle Gehlen, ALF Licensor - LT C Jennifer Siharath, ALF Licensor Richard Western, NCI, ALF Complaint Investigator From: DSHS, Aging and Long-Term Support Administration Residential Care Services, Region 3 , Unit I 800 NE 136th Ave Ste 200 Vancouver, WA 98684 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. 12/12/2024 R6sidential 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. This document was prepared by Residential Care Services for the Locator website. statement of Deficiencies License#: 2535 Compliance Determination # 51041 Plan of Correction Bonaventure of Vancouver Completion Date Page 2 of21 Licensee: BONAVENTURE OF VANCOUVER LLC 12/05/2024 r Date WAC 388-78A-2320 Intermittent nursing services systems. (1) When an assisted living facility provides intermittent nursing services to any resident, either directly or indirectly, the assisted living facility must: (a) Develop and implement systems that support and promote the safe practice of nursing for each resident; and (b) Ensure the requirements of chapters 18.79 RCW and 246-840 WAC are met. (2) The assisted living facility providing nursing services, either directly or indirectly, must ensure that the nursing services systems include: (a) Nursing services supervision; (b) Nurse delegation, if provided; (c) Initial and on-going assessments of the nursing needs of each resident; (d) Development of, and necessary amendments to, the nursing component of the negotiated service agreement for each resident; (e) Implementation of the nursing component of each resident's negotiated service agreement; and (f) Availability of the supervisor, in person, by pager, or by telephone, to respond to residents' needs on the assisted living facility premises as necessary. (3) The assisted living facility must ensure that all nursing services, including nursing supervision, assessments, and delegation, are provided in accordance with applicable statutes and rules, including, but not limited to: (a) Chapter 18.79 RCW, Nursing care; (b) Chapter 18.88A RCW, Nursing assistants; (c) Chapter 246-840 WAC, Practical and registered nursing; (d) Chapter 246-841 WAC, Nursing assistants; and (e) Chapter 246-888 WAC, Medication assistance. This requirement was not met as evidenced by: Based on interview and record review, the facility failed to ensure the nurse delegation requirements were met when the nurse delegator failed to delegate 9 of 14 Medication Aids (Staff D, E, H, I, J, K, L, M, and N) prior to administering medications to 1 of 1 sampled resident (Resident 4). This failure placed this resident at risk for harm and injury due to untrained and unsupervised care staff. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2535 Compliance Determination #51041 Plan of Correction Bonaventure of Vancouver Completion Date Page 3 of21 Licensee: BONAVENTURE OF VANCOUVER LLC 12/05/2024 Findings included ... WAC 246-840-930 Criteria for delegation. (1) In community-based and in-home care settings, before delegating a nursing task, the registered nurse delegator shall decide if a task is appropriate to delegate based on the elements of the nursing process: ASSESS, PLAN, IMPLEMENT, EVALUATE. ASSESS (2) The setting allows delegation because it is a community-based care setting as defined by RCW 18.79.260 (3)(e)(i) or an in-home care setting as defined by RCW 18.79.260 (3)(e)(ii). (3) Assess the patient's nursing care needs and determine the patient's condition is stable and predictable. A patient may be stable and predictable with an order for sliding scale insulin or terminal condition. (4) Determine the task to be delegated is within the delegating nurse's area of responsibility. (5) Determine the task to be delegated can be properly and safely performed by the nursing assistant or home care aide. The registered nurse delegator assesses the potential risk of harm for the individual patient (6) Analyze the complexity of the nursing task and determine the required training or additional training needed by the nursing assistant or home care aide to competently accomplish the task. The registered nurse delegator identifies and facilitates any additional training of the nursing assistant or home care aide needed prior to delegation. The registered nurse delegator ensures the task to be delegated can be properly and safely performed by the nursing assistant or home care aide. (7) Assess the level of interaction required. Consider language or cultural diversity affecting communication or the ability to accomplish the task and to facilitate the interaction. (8) Verify that the nursing assistant or home care aide: (a) Is currently registered or certified as a nursing assistant or home care aide in Washington state without restriction; (b) Has completed both the basic caregiver training and core delegation training before performing any delegated task; (c) Has evidence as required by the department of social and health services of successful completion of nurse delegation core training; (d) Has evidence as required by the department of social and health services of successful completion of nurse delegation special focus on diabetes training when providing insulin injections to a diabetic client; and (e) Is willing and able to perform the task in the absence of direct or immediate nurse supervision and accept responsibility for their actions. (9) Assess the ability of the nursing assistant or home care aide to competently perform the delegated nursing task in the absence of direct or immediate nurse supervision. (10) If the registered nurse delegator determines delegation is appropriate, the nurse: (a) Discusses the delegation process with the patient or authorized representative, including the level of training of the nursing assistant or home care aide delivering care. (b) Obtains written consent The patient, or authorized representative, must give written, consent to the delegation process under chapter 7. 70 RCW. Documented verbal consent of patient or authorized representative may be acceptable if written consent is obtained within 30 days; electronic consent is an acceptable format Written consent is This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License#: 2535 Compliance Determination# 51041 Plan of Correction Bonaventure of Vancouver Completion Date Page 4 of21 Licensee: BONAVENTURE OF VANCOUVER LLC 12/05/2024 only necessary at the initial use of the nurse delegation process for each patient and is not necessary for task additions or changes or if a different nurse, nursing assistant, or home care aide will be participating in the process. PLAN (11) Document in the patient's record the rationale for delegating or not delegating nursing tasks. (12) Provide specific, written delegation instructions to the nursing assistant or home care aide with a copy maintained in the patient's record that includes: (a) The rationale for delegating the nursing task; (b) The delegated nursing task is specific to one patient and is not transferable to another patient; (c ) The delegated nursing task is specific to one nursing assistant or one home care aide and is not transferable to another nursing assistant or home care aide; (d ) The nature of the condition requiring treatment and purpose of the delegated nursing task; (e) A clear description of the procedure or steps to follow to perform the task; (f) The predictable outcomes of the nursing task and how to effectively deal with them; (g) The risks of the treatment; (h) The interactions of prescribed medications; (i) How to observe and report side effects, complications, or unexpected outcomes and appropriate actions to deal with them, including specific parameters for notifying the registered nurse delegator, health care provider, or emergency services; G) The action to take in situations where medications and/or treatments and/or procedures are altered by health care provider orders, including: (i) How to notify the registered nurse delegator of the change; (ii) The process the registered nurse delegator uses to obtain verification from the health care provider of the change in the medical order; and (iiQ The process to notify the nursing assistant or home care aide of whether administration of the medication or performance of the procedure and/or treatment is delegated or not; (k) How to document the task in the patient's record; (I) Document teaching done and a return demonstration, or other method for verification of competency; and (m) Supervision shall occur at least every 90 days. With delegation of insulin injections, the supervision occurs at least every two weeks for the first four weeks, and may be more frequent. (13) The administration of medications may be delegated at the discretion of the registered nurse delegator, including insulin injections. Any other injection (intramuscular, intradermal, subcutaneous, intraosseous, intravenous, or otherwise) is prohibited. The registered nurse delegator provides to the nursing assistant or home care aide written directions specific to an individual patient. IMPLEMENT (14) Delegation requires the registered nurse delegator teach the nursing assistant or home care aide how to perform the task, including return demonstration or other method of verification of competency as determined by the registered nurse delegator. (15) The registered nurse delegator is accountable and responsible for the delegated nursing task. The registered nurse delegator monitors the performance of the task(s) to assure compliance with established standards of practice, policies and procedures and appropriate documentation of the task(s). EVALUATE (16) The registered nurse delegator evaluates the patient's responses to the delegated nursing care and to any modification of the nursing components of the patient's plan of This document was prepared by Residential Care Services for the Locator website. statement of Deficiencies License#: 2535 Compliance Determination # 51041 Plan of Correction Bonaventure of Vancouver Completion Date Page 5 of21 Licensee: BONAVENTURE OF VANCOUVER LLC 12/05/2024 care. (17) The registered nurse delegator supervises and evaluates the performance of the nursing assistant or home care aide, including direct observation or other method of verification of competency of the nursing assistant or home care aide. The registered nurse delegator reevaluates the patient's condition, the care provided to the patient, the capability of the nursing assistant or home care aide, the outcome of the task, and any problems. (18) The registered nurse delegator ensures safe and effective services are provided. Reevaluation and documentation occur at least every 90 days. Frequency of supervision is at the discretion of the registered nurse delegator and may be more often based upon nursing assessment During an unannounced licensing full inspection on 12/02/2024 at 12:30 PM, record review of the facility's resident characteristics roster provided, documented three residents requiring nurse delegation. Resident 4 (R4) On 12/03/2024 at 10:15 AM, R4's records showed that R4 admitted to the facility on /2024 with various diagnoses including and . Record review of R4's nurse delegation records showed a consent signed on 10/15/2024. Record review of R4's nurse delegation: nursing visit, dated 10/09/2024, showed only five staff delegated: - Staff A, Executive Director, hired 07/04/2017. - Staff 0, medication aide, hired on 08/18/2024. - Staff P, medication aide, hired on 03/04/2020. - Staff Q, caregiver, hired on 09/22/2024. - Staff R, medication aide, hired on 08/02/2023. Record review of R4's medication administration record (MAR) dated 09/01/2024 to 12/02/2024 showed that the following staff administered insulin to R4: - Staff D, medication aide, hired on 05/24/2023. - Staff E, medication aide, hired on 11/09/2023. - Staff H, former employee. Hire and termination date unknown. - Staff I, medication aide, hired 07/14/2023. - Staff J, medication aide, hired on 03/15/2023. - Staff K, medication aide, hired on 04/22/2024. - Staff L, medication aide, hired on 06/05/2024. - Staff M, caregiver, hired on 05/09/2024. - Staff N, caregiver, hired on 12/27/2024. During an exit interview on 12/05/2024 at 11:10 AM, Staff C, Registered Nurse, This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License#: 2535 Compliance Determination # 51041 Plan of Correction Bonaventure of Vancouver Completion Date Page 6 of21 Licensee: BONAVENTURE OF VANCOUVER LLC 12/05/2024 acknowledged that the nurse delegation consent for R4 was signed after staff had been administering oral medications, insulin, and monitoring blood sugars for R4 and that 9 of the 14 medication aides that had been administering medications to R4 had not been delegated. 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, Bonaventurr of V!!),COuver is or will be in compliance with this law and I or regulation on (Date) D I J q f;l 5 . In addition, I will implement a system to monitor and ensure continued compliance with this requirement ) Date WAC 388-78A-2210 Medication services. (1) An assisted living facility providing medication service, either directly or indirectly, must (b) Develop and implement systems that support and promote safe medication service for each resident. This requirement was not met as evidenced by: Based on interview and record review, the facility failed to develop and implement systems that support and promote safe medication service when 3 of 12 residents (Resident 4, 6 and 12) were administered medications not as prescribed. This failure placed these two residents at risk of harm from inconsistent or improper medication management. Findings included ... Resident 4 (R4) During an unannounced full inspection on 12/03/2024 at 10:15 AM, R4's records showed that R4 admitted to the facility on /2024 with various diagnoses including and . Record review of R4's medication administration record (MAR), dated 09/01/2024-12/02/2024, showed that R4 was receiving a medication, carvedilol, twice a day to regulate R4's blood pressure. This document was prepared by Residential Care Services for the Locator website. statement of Deficiencies License #: 2535 Compliance Determination # 51041 Plan of Correction Bonaventure of Vancouver Completion Date Page 7 of21 Licensee: BONAVENTURE OF VANCOUVER LLC 12/05/2024 Review of R4's September and October of 2024 MAR's, showed documentation that between 09/27/2024 - 10/05/2024, the facility had the wrong dose of the medication and was in communication with the pharmacy to receive the correct dose. During this time, it was documented that the medication was administered five times. No other documentation was found to show why the medication was given when the facility had the wrong dose. Resident 6 (R6) On 12/03/2024 at 10:30 AM, R6's records showed that R65 admitted to the facility on /2022 with various diagnoses including and . Record review of R6's MAR's, dated 09/01/2024 - 12/02/2024, showed that R6 was receiving a medication, cromolyn sodium, three times a day to treat symptoms of a respiratory disease. Review of R6's September of 2024 MAR, showed documentation throughout the month that the medication was not given with the explanation that "medication has not arrived." The following are the dates this medication was not given: - 09/01/2024: morning and afternoo_n dose - 09/02/2024: morning and afternoon dose - 09/03/2024: morning and evening dose - 09/14/2024: morning and afternoon dose - 09/15/2024: morning dose - 09/21/2024: evening dose - 09/22/2024: morning dose Resident 12 (R12) On 10/04/2024 at 11:00 AM, R12's records showed that R12 admitted to the facility on /2024 with various diagnoses including . Record review of R12's MAR's, dated 09/01/2024-12/02/2024, showed that R12 was receiving a medication, prednisone, to treat inflammation. Review of R12's October of 2024 MAR, showed documentation that between 10/13/2024-10/28/2024, the medication was not given with the explanation that "med not arrived." Between that time frame, it was documented that the medication was given on 10/20/2024, 10/21/2024, and 10/27/2024. During an exit interview on 12/05/2024 at 11:10 AM, Staff A, Executive Director, acknowledged the need for additional training for medication assistance and administration. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2535 Compliance Determination # 51041 Plan of Correction Bonaventure of Vancouver Completion Date Page 8 of21 Licensee: BONAVENTURE OF VANCOUVER LLC 12/05/2024 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, BonavenhJri of) {jncouver is or will be in compliance with this law and I or regulation on (Date) /}j _J ': 1__: )..5 . In addition, I will implement a system to monitor and ensure continued compliance with this requirement WAC 388-78A-2474 Training and home care aide certification requirements. (2) The assisted living facility must ensure all assisted living facility administrators, or their designees, and caregivers hired on or after January 7, 2012 meet the long-term care worker training requirements of chapter 388-112A WAC, including but not limited to: (b) Basic; (c ) Specialty for dementia, mental illness and/or developmental disabilities when serving residents with any of those primary special needs; (e ) Continuing education. This requirement was not met as evidenced by: Based on interview and record review, the facility failed to ensure 3 of 3 sampled staff (Staff C, D, and E) had completed and/or had documentation of them completing their required basic training, specialty training, and/or 12 hours of continuing education (CEUs) per regulation. This failure placed all residents at risk for harm due to staff not being properly trained. Findings included ... During an unannounced licensing full inspection on 12/02/2024 at 1:00 PM, the department received the requested staff documents. Staff C Record review for Staff C, Registered Nurse (RN), showed that Staff C was hired on 09/25/2023. Review of Staff C's personnel records showed no documentation that Staff C had completed the required dementia and mental health specialty training. In an interview on 12/04/2024 at 1 :05 PM, Staff C stated that they were unaware that RN's were required to take the specialty training. This document was prepared by Residential Care Services for the Locator website. statement of Deficiencies License#: 2535 Compliance Determination# 51041 Plan of Correction Bonaventure of Vancouver Completion Date Page 9 of21 Licensee: BONAVENTURE OF VANCOUVER LLC 12/05/2024 Staff D Record review for Staff D, Assisted Living Director, showed that Staff D was hired on 05/24/2023. Review of Staff D's personnel records no documentation that Staff D had completed the required 70- hour basic training, the annual 12 hours of continuing education, or the dementia and mental health specialty training. Staff E Record review for Staff E, Medication Aide, showed that Staff E was hired on 11/09/2023. Review of Staff E's personnel records no documentation that Staff E had completed the required annual 12 hours of continuing education, or the dementia and mental health specialty training. During an exit interview on 12/05/2024 at 11:10 AM, Staff A, Executive Director, acknowledged the department's findings. 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, Bonaventuri of V<jin~ouver is or QI Jqt_c}_S . 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 A~?!fi2ve) Date WAC 388-78A-2090 Full assessment topics. The assisted living facility must obtain sufficient information to be able to assess the capabilities, needs, and preferences for each resident, and must complete a full assessment addressing the following, within fourteen days of the resident's move-in date, unless extended by the department for good cause: (1) Individual's recent medical history, including, but not limited to: (a) A licensed medical or health professional's diagnosis, unless the resident objects for religious reasons; (b) Chronic, current, and potential skin conditions; or (c ) Known allergies to foods or medications, or other considerations for providing care or services. (2) Currently necessary and contraindicated medications and treatments for the individual, including: This document was prepared by Residential Care Services for the Locator website. statement of Deficiencies License #: 2535 Compliance Determination # 51041 Plan of Correction Bonaventure of Vancouver Completion Date Page10 of21 Licensee: BONAVENTURE OF VANCOUVER LLC 12/05/2024 (a) Any prescribed medications, and over-the-counter medications commonly taken by the individual, that the individual is able to independently self-administer, or safely and accurately direct others to administer to him/her; (b) Any prescribed medications, and over-the-counter medications commonly taken by the individual, that the individual is able to self-administer when he/she has the assistance of a caregiver; and (c) Any prescribed medications, and over-the-counter medications commonly taken by the individual, that the individual is not able to self-administer, and needs to have administered to him or her. (3) The individual's nursing needs when the individual requires the services of a nurse on the assisted living facility premises. (4) Individual's sensory abilities, including: (a) Vision; and (b) Hearing. (5) Individual's communication abilities, including: (a) Modes of expression; (b) Ability to make self understood; and ( c) Ability to understand others. (6) Significant known behaviors or symptoms of the individual causing concern or requiring special care, including: (a) History of substance abuse; (b) History of harming self, others, or property; or (c) Other conditions that may require behavioral intervention strategies; (d) Individual's ability to leave the assisted living facility unsupervised; and ( e) Other safety considerations that may pose a danger to the individual or others, such as use of medical devices or the individual's ability to smoke unsupervised, if smoking is permitted in the assisted living facility. (7) Individual's special needs, by evaluating available information, or if available information does not indicate the presence of special needs, selecting and using an appropriate tool, to determine the presence of symptoms consistent with, and implications for care and services of: (a) Mental illness, or needs for psychological or mental health services, except where protected by confidentiality laws; (b) Developmental disability; (c) Dementia. While screening a resident for dementia, the assisted living facility must: (i) Base any determination that the resident has short-term memory loss upon objective evidence; and This document was prepared by Residential Care Services for the Locator website. statement of Deficiencies License #: 2535 Compliance Determination # 51041 Plan of Correction Bonaventure of Vancouver Completion Date Page 11 of21 Licensee: BONAVENTURE OF VANCOUVER LLC 12/05/2024 Oil Document the evidence in the resident's record. (d ) Other conditions affecting cognition, such as traumatic brain injury. (8) Individual's level of personal care needs, including: (a) Ability to perform activities of daily living; (b) Medication management ability, including: CT) The individual's ability to obtain and appropriately use over-the-counter medications; and Oi) How the individual will obtain prescribed medications for use in the assisted living facility. (9) Individual's activities, typical daily routines, habits and service preferences. (10) Individual's personal identity and lifestyle, to the extent the individual is willing to share the information, and the manner in which they are expressed, including preferences regarding food, community contacts, hobbies, spiritual preferences, or other sources of pleasure and comfort (11) Who has decision-making authority for the individual, including: (a) The presence of any advance directive, or other legal document that will establish a substitute decision maker in the future; (b) The presence of any legal document that establishes a current substitute decision maker; and (c) The scope of decision-making authority of any substitute decision maker. This requirement was not met as evidenced by: Based on interview and record review, the facility failed to complete a full assessment within 14 days of the resident's admission to the facility for 2 of 6 sampled residents (Residents 4, and 9). This failure placed these two residents at risk of their care needs not being met Findings included ... Resident 4 (R4) During an unannounced full inspection on 12/03/2024 at 10:15 AM, R4's records showed that R4 admitted to the facility on /2024 with various diagnoses including and . Record review of R4's assessments showed a preadmission assessment dated 05/23/2024. No assessments were found within 14 days of R4 admitting to the facility. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2535 Compliance Determination # 51041 Plan of Correction Bonaventure of Vancouver Completion Date Page 12 of21 Licensee: BONAVENTURE OF VANCOUVER LLC 12/05/2024 Resident 9 (R9) During record review, R9's records showed that R9 admitted to the facility on /2024 with various diagnoses including chronic . Record review of R9's assessments showed a preadmission assessment undated. No assessments were found within 14 days of R9 admitting to the facility. During an exit interview on 12/05/2024 at 11:10 AM, Staff C, Registered Nurse, acknowledged that the 14-day assessments for R4 and R9 had not been completed. Plan/Attestation Statement I hereby certify that I have reviewed this report and have taken or will take active ..2f. measures to correct this deficiency. By taking this action, Bonaventur~ V,incouver is or will be in compliance with this law and/ or regulation on (Date) DI l.ef:!1 ,I o25 . In addition, I will implement a system to monitor and ensure continued compliance with this requirement ~)ll/2 ' Adfinistrator (or Representative) Date) WAC 388-78A-2130 Service agreement planning. The assisted living facility must: (2) Complete the negotiated service agreement for each resident using the resident's preadmission assessment, initial resident service plan, and full assessment information, within thirty days of the resident moving in; This requirement was not met as evidenced by: Based on interview and record review, the facility failed to complete the Negotiated Service Agreement (NSA) upon admission and/or within 30 days of admission to the facility for 2 of 6 sampled residents (Resident 4 and 9). This failure placed these two residents at risk for proper care needs being unmet Findings included ... Resident 4 (R4) During an unannounced full inspection on 12/03/2024 at 10:15 AM, R4's records showed that R4 admitted to the facility on /2024 with various diagnoses including This document was prepared by Residential Care Services for the Locator website. statement of Deficiencies License #: 2535 Compliance Determination # 51041 Plan of Correction Bonaventure of Vancouver Completion Date Page 13 of21 Licensee: BONAVENTURE OF VANCOUVER LLC 12/05/2024 and . Record review of R4's NSAs showed an NSA dated 05/23/2024 that was signed three months later, on 08/25/2024 by the resident or the resident's responsible party. An NSA dated 06/27/2024 was also found and signed three months later, on 09/27/2024. No documentation was provided to show that either NSAs were reviewed and/or agreed upon by the resident or resident's responsible party at the time of the NSA. Resident 9 (R9) Review of R9's records showed that R9 admitted to the facility on /2024 with various diagnoses including . Record review of R9's NSAs showed an initial NSAs dated 07/24/2024. No other NSA was found within 30-days of R9's admission into the facility. During an exit interview on 12/05/2024 at 11:1 O AM, Staff C, Registered Nurse, acknowledged the department's findings. 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, Bonavel).,b,lri of V!ncouver is or will be in compliance with this law and / or regulation on (Date) {/ L ,_ I 1 (pl. S . In addition, I will implement a system to monitor and ensure continued compliance with this requirement I ~ I;µ/-- 1:1 d-l/- Admmistrator (or Representative) Date WAC 388-78A-2390 Resident records. The assisted living facility must maintain adequate records concerning residents to enable the assisted living facility: (1) To effectively provide the care and services agreed upon with the resident; and (2) To respond appropriately in emergency situations. This requirement was not met as evidenced by: This document was prepared by Residential Care Services for the Locator website. statement of Deficiencies License#: 2535 Compliance Determination #51041 Plan of Correction Bonaventure of Vancouver Completion Date Page 14 of21 Licensee: BONAVENTURE OF VANCOUVER LLC 12/05/2024 Based on interview and record review, the facility failed to maintain a current characteristic roster accurately documenting resident care needs and services for 3 of 12 sampled residents (Resident 2, 8, and 10). This failure placed these residents at risk for proper care needs not being met. Findings included ... Resident 2 (R2) During an unannounced licensing full inspection on 11/04/2024 at 1:20 PM, R2's records showed that R2 admitted to the facility on /2022 with various diagnoses including . Record review of R2's assessment, dated 09/20/2024, documented that R2 utilizes an assistive device. Record review of R2's negotiated service agreement (NSA), dated 06/06/2024, also documented that R2 utilizes an assistive device. Review of the facility's resident characteristics roster (RCR) showed no documentation that R2 has or utilizes an assistive device. The RCR documented that R2 was receiving nurse delegation services. Review of R2's records showed no nurse delegation documents. During an interview on 12/04/2024 at 1: 05 PM, Staff C, Registered Nurse (RN), confirmed that R2 uses a walker and stated that R2 had nurse delegation for wound care, but no longer requires nurse delegation as the wound care is now basic first aid. Resident 8 (R8) During an unannounced full inspection on 12/03/2024 at 11 :35 AM, R8's records showed that R8 admitted to the facility on /2021 with various diagnoses including and . Record review of the facility's resident characteristics roster showed that R8 was a fall risk. Record review of R8's NSA, dated 09/01/2024, documented that R8 was not a fall risk. During an interview on 12/04/2024 at 1 :05 PM, Staff C confirmed that R8 is not a fall This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2535 Compliance Determination # 51041 Plan of Correction Bonaventure of Vancouver Completion Date Page 15 of21 Licensee: BONAVENTURE OF VANCOUVER LLC 12/05/2024 risk. Resident 1 O (R10) On 12/04/2024 at 9:30 AM, R10's records showed that R10 admitted to the facility on /2023 with various diagnoses including and . Review of the facility's RCR documented that R10 requires administration for medication management, that R 1O is a non-insulin dependent diabetic, and has pressure ulcers. Review of R 1 O's records showed no nurse delegation documents for administration with medications. A diagnosis of could not be found on any of R1 O's records. Record review of R1 O's NSA dated 09/14/2024, documented that R10 has no wounds or skin issues. During an interview on 12/04/2024 at 1:05 PM, Staff C confirmed that R10 is not a diabetic and currently has no wounds. During an exit interview on 12/05/2024 at 11:10 AM, Staff A, Executive Director, acknowledged that the resident characteristics roster had discrepancies. 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 'fancouver is or will be in compliance with this law and I or regulation on (Date) Q// 1C f Ld-5 . In addition, I will implement a system to monitor and ensure continued compliance with this requirement WAC 388-78A-2480 Tuberculosis Testing Required. (1) The assisted living facility must develop and implement a system to ensure each staff person is screened for tuberculosis within three days of employment This document was prepared by Residential Care Services for the Locator website. statement of Deficiencies License#: 2535 Compliance Determination# 51041 Plan of Correction Bonaventure of Vancouver Completion Date Page 16 of21 Licensee: BONAV ENTURE OF VANCOUVER LLC 12/05/2024 This requirement was not met as evidenced by: Based on interview and record review, the facility failed to complete tuberculosis (TB) (an infectious bacterial disease that often attacks the lungs) testing within three days of hire for 3 of 3 sampled staff (Staff C, D, and E) per regulations. This failure placed all staff and residents at risk for possible exposure and harm from a communicable disease. Findings included ... During an unannounced licensing full inspection on 12/02/2024 at 1:00 PM, the department received the requested staff documents. Staff C Record review for Staff C, Registered Nurse (RN), showed that Staff C was hired on 09/25/2023. Review of Staff C's personnel records showed a TB test was initiated on 02/21/2024. No documentation was found to show that Staff C had a TB test within three days of hire. Staff D Record review for Staff D, Assisted Living Director, showed that Staff D was hired on 05/24/2023. Review of Staff D's personnel records showed a TB test was initiated on 10/07/2023. No documentation was found to show that Staff D had a TB test within three days of hire or by 08/31/2023 when the facility was back in compliance for TB testing. Staff E Record review for Staff E, Medication Aide, showed that Staff E was hired on 11/09/2023. Review of Staff E's personnel records showed a TB test was initiated on 01/02/2024. No documentation was found to show that Staff E had a TB test within three days of hire. During an exit interview on 12/05/2024 at 11:10 AM, Staff A, Executive Director, acknowledged that the TB tests for Staff C, D, and E were initiated late. 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, Bonaventuj of Vpncouver is or 0 I I CJ t,:} 5 . 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 A ~ Date This document was prepared by Residential Care Services for the Locator website. statement of Deficiencies License#: 2535 Compliance Determination #51041 Plan of Correction Bonaventure of Vancouver Completion Date Page 17 of21 Licensee: BONAVENTURE OF VANCOUVER LLC 12/05/2024 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 interview and record review, the facility failed to ensure 3 of 3 sampled pets living in the facility had regular examinations and immunizations and had been certified by a veterinarian to be free of diseases transmittable to humans. This failure placed all staff and residents at risk for possible exposure and harm from a transmittable disease. Findings included ... During an unannounced licensing full inspection on 12/03/2024 at 12:00 PM, the department reviewed the requested pet records. Review of the facility's pet records showed a feline with a rabies vaccination that had expired on 04/06/2024, a canine with a rabies vaccination that had expired on 07/19/2023, and another feline that had a rabies vaccination that had expired on 06/15/2024. On 12/04/2024, the facility provided the department with two updated pet vaccination records. No additional documents were provided to show that the two sampled felines and one sampled canine were current on vaccinations. In an exit interview on 12/05/2024 at 11:10 AM, Staff B, Assistant Executive Director, acknowledged that there were pets living in the facility that had no documentation that they have had regular examinations and immunizations and have been certified by a veterinarian to be free of diseases transmittable to humans since moving into the facility. Plan/Attestation Statement This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License#: 2535 Compliance Determination# 51041 Plan of Correction Bonaventure of Vancouver Completion Date Page 18 of21 Licensee: BONAVENTURE OF VANCOUVER LLC 12/05/2024 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, Bonave0tuT;o_f.,,kncouver is or 85 . will be in compliance with this law and/ or regulation on (Date) / Vf In addition, I will implement a system to monitor and ensure continued compliance with this requirement A ~ WAC 388-78A-2665 Resident rights Notice Policy on accepting medicaid as a payment source. The assisted living facility must fully disclose the facility's policy on accepting medicaid payments. The policy must: (1) Clearly state the circumstances under which the assisted living facility provides care for medicaid eligible residents and for residents who become eligible for medicaid after admission; (2) Be provided both orally and in writing in a language that the resident understands; (3) Be provided to prospective residents, before they are admitted to the home; (4) Be provided to any current residents who were admitted before this requirement took effect or who did not receive copies prior to admission; (5) Be written on a page that is separate from other documents and be written in a type font that is at least fourteen point; and (6) Be signed and dated by the resident and be kept in the resident record after signature. This requirement was not met as evidenced by: Based on interview and record review, the facility failed to ensure a Medicaid policy was on a page separate from other documents and was signed on or before admission for 3 of 9 sampled residents (Resident 2, 3, and 4). This failure placed these three residents at risk of not being aware of their rights as they pertain to Medicaid. Findings included ... Resident 2 (R2) During an unannounced full inspection on 12/03/2024 at 9:20 AM, R2's records showed that R2 admitted to the facility on /2021 with various diagnoses including and . During review of R2's records, a Medicaid policy was found, signed by the resident or This document was prepared by Residential Care Services for the Locator website. statement of Deficiencies License#: 2535 Compliance Determination # 51041 Plan of Correction Bonaventure of Vancouver Completion Date Page 19 of21 Licensee: BONAVENTURE OF VANCOUVER LLC 12/05/2024 resident's responsible party on 07/05/2023. Resident 3 (R3) On 12/03/2024 at 9:38 AM, R3's records showed that R3 admitted to the facility on /2024 with various diagnoses including . During review of R3's records, a Medicaid policy was found, signed by the resident or resident's responsible party on 12/03/2024. Resident 4 (R4) On 12/03/2024 at 10:15 AM, R4's records showed that R4 admitted to the facility on /2024 with various diagnoses including and . During initial review of R4's records, no Medicaid policy was found. On 12/04/2024 at 11:50 AM, the facility provided a Medicaid policy for R4 that was signed by the resident or resident's responsible party on 12/03/2024. In an exit interview on 12/05/2024 at 11:10 AM, Staff A, Executive Director, acknowledged that the Medicaid policies for R2, 3, and 4 were not completed and/or signed late. 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, Bonave~ure,of va7couver is or Tl. CJ will be in compliance with this law and / or regulation on (Date) I I { _'95 . In addition, I will implement a system to monitor and ensure continued compliance with this requirement Date WAC 388-78A-2730 Licensee's responsibilities. (2) The licensee must (b) Maintain and post in a size and format that is easily read, in a conspicuous place on the assisted living facility premises: This document was prepared by Residential Care Services for the Locator website. statement of Deficiencies License#: 2535 Compliance Determination # 51041 Plan of Correction Bonaventure of Vancouver Completion Date Page20 of21 Licensee: BONAVENTURE OF VANCOUVER LLC 12/05/2024 Qii) A copy of the report, including the cover letter, and plan of correction of the most recent full inspection conducted by the department. This requirement was not met as evidenced by: Based on observation, record review, and interview, the facilrry failed to post a copy, including the cover letter, and plan of correction of the most recent full inspection conducted by the department. This failure placed residents and/or any individual visiting the facilrry at risk for being uninformed of the facilities current and past deficiencies. Findings included ... During an unannounced licensing full inspection on 12/02/2024 at 10:05, the department observed the facility's survey binder containing the facility's last full inspection report. Record review of the facility's survey binder showed a full inspection report from 2021. No report was found for the full inspection conducted in 2023. In an exit interview on 12/05/2024 at 11 :10 AM, Staff A, Executive Director, acknowledged that the facility's survey binder was not up to date with the most recent full inspection report. 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, BonaveAtur7 pqVf 9'ncouver is or will be in compliance with this law and/ or regulation on (Date) (l_/ _)'_Ii).5 . In addition, I will implement a system to monitor and ensure continued compliance with this requirement Ai:1fdef!!J!:6(P, Date WAC 388-78A-3140 Responsibilities during inspections. The assisted living facility must: (2) Provide requested records to the representatives of the department; and This requirement was not met as evidenced by: This document was prepared by Residential Care Services for the Locator website. statement of Deficiencies License #: 2535 Compliance Determination# 51041 Plan of Correction Bonaventure of Vancouver Completion Date Page 21 of21 Licensee: BONAVENTURE OF VANCOUVER LLC 12/05/2024 Based on record review and interview, the facility failed to provide accurate documentation when requested by the Department during their full licensing inspection. This failure placed all residents at risk of care from a facility not in compliance with governing rules and regulations. Findings included ... During an unannounced full licensing inspection on 12/03/2024 at 11 :30 AM, the department requested to Staff C, Registered Nurse, the nurse delegation credentials for the facilities delegated staff. In an interview to go over preliminary findings, on 12/04/2024 at 1 :05 PM, the department again requested from Staff C, the nurse delegation credentials for the facilities delegated staff. On 12/04/2024 at 2:15 PM, the department requested from Staff A, Executive Director, the nurse delegation credentials for the facilities delegated staff, to be delivered by the following morning. On 12/05/2024 at 11:00 AM, no delegation credentials were provided to the department In an exit interview on 12/05/2024 at 11 :1 0 AM, Staff A, acknowledged the departments repeated requests for documents that were not received. 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 V~ncouver is or will be in compliance with this law and I or regulation on (Date) QI J' 1 /;).5 . In addition, I will implement a system to monitor and ensure continued compliance with _this 1requ:ire:m!enit £1J!t) Date

Residential Care Services Investigation Summary Report Provider/Facility: Bonaventure of Vancouver Provider Type: Assisted Living Facility License/Cert.#: 2535 Intake ID: 182606 Compliance Determination #: 60983 Region/Unit #: RCS Region 3 / Unit I Investigator: Richard Westom Investigation Date(s): 06/11/2025 through 07/01/2025 Complainant Contact Date(s): 06/11/2025 Allegation(s): 1. neglect. Resident not receiving ordered medications. Investigation Methods: Sample: Total residents: 88 Resident sample size: 3 Closed records sample size: 0 Observations: Identified resident Residents Resident rooms Staff to resident interactions Resident to resident interactions Medication administration Interviews: Identified resident Nursing staff Residents Record Reviews: Medical records Facility policies Investigation Summary: 1. neglect. After interviews and record review the facility failed to provide all medications for 1 of 3 residents reviewed. Failed practice. 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 800 NE 136th Ave Ste 200, Vancouver, WA 98684 Statement of Deficiencies License #: 2535 Compliance Determination # 60983 Plan of Correction Bonaventure of Vancouver Completion Date Page 1 of 4 Licensee: BONAVENTURE OF VANCOUVER LLC 07/01/2025 You are required to be in compliance at all times with all licensing laws and regulations to maintain your Assisted Living Facility license. The department completed data collection for an unannounced on-site complaint investigation on 06/11/2025 of: Bonaventure of Vancouver 9317 NE 86th Street Vancouver, WA 98662 This document references the following complaint number(s): 182606 The following sample was selected for review during the unannounced on-site visit: 3 of 88 current residents and 0 former residents. The department staff that investigated the Assisted Living Facility: Richard Westom, NCI, ALF Complaint Investigator From: DSHS, Aging and Long-Term Support Administration Residential Care Services, Region 3 , Unit I 800 NE 136th Ave Ste 200 Vancouver, WA 98684 This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2535 Compliance Determination # 60983 Plan of Correction Bonaventure of Vancouver Completion Date Page 2 of 4 Licensee: BONAVENTURE OF VANCOUVER LLC 07/01/2025 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-2240 Nonavailability of medications. When the assisted living facility has assumed responsibility for obtaining a resident's prescribed medications, the assisted living facility must obtain them in a correct and timely manner. This requirement was not met as evidenced by: Based on interview and record review, the facility failed to obtain prescribed medications for 1 of 3 sampled residents (Resident 1[R1]) who were reviewed for availability of medications. This failure resulted in R1 not receiving medications as ordered by the physician and placed R1 at risk of harm by not receiving the required medications. Findings included… Review of undated facility policy titled “Medication Technician & QMAP Training” documented staff shall carry out all medication and treatment orders as prescribed. Review of facility records showed R1 admitted to the facility on /2022 with diagnoses to include ( ), ( ). Review of R1’s evaluation and service agreement, dated 07/09/2025, documented staff will order and administer all medications. During an unannounced visit on 06/11/2025 at 1:05 PM, Staff A, administrator, stated that the facility is ordering and administering R1’s medications. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2535 Compliance Determination # 60983 Plan of Correction Bonaventure of Vancouver Completion Date Page 3 of 4 Licensee: BONAVENTURE OF VANCOUVER LLC 07/01/2025 Review of R1’s Medication Administration Record (MAR), dated June 2025, documents the following medications were circled as not given on 06/13/2025, 06/14/2025 and 06/19/2025: • Multivitamin (vitamin supplement), • Sennosides (medication used for constipation), • Vitamin B-12 (vitamin supplement), • Vitamin C (vitamin supplement), • Vitamin D3 (vitamin supplement), • Aspirin (medication used for clot prevention), • Ferrous sulfate (vitamin supplement), • Pantoprazole (medication used for acid reflux), • Rosuvastatin calcium (medication used for high cholesterol). Review of facility documentation on 06/30/2025, titled “MAR exceptions,” documented the reason the above medications had not been administered on 06/13/2025, 06/14/2025 and 06/19/2025 was that they had not arrived from the pharmacy. In an interview on 06/25/2025 at 11:09 AM, Staff B, facility registered nurse (RN), stated they order medications for residents. In an interview on 07/01/2025 at 10:35 AM, Staff A, stated pharmacy won’t fill supplements, staff need to call family to bring them in and that it’s not acceptable for R1 to miss medications. In an interview on 07/01/2025 at 11:05 AM, R1 stated “nobody made me aware that I wasn’t getting all my medications,” and that the facility orders all my medications. In an interview on 07/01/2025 at 11:38 AM, Staff C, medication technician (MT), stated the MT’s are mostly new hires, and we didn’t know we couldn’t get supplements from the pharmacy and that it is not ok R1 was missing medications. This is a recurring deficiency from 11/23/2023. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2535 Compliance Determination # 60983 Plan of Correction Bonaventure of Vancouver Completion Date Page 4 of 4 Licensee: BONAVENTURE OF VANCOUVER LLC 07/01/2025 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 Vancouver 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.

This document was prepared by Residential Care Services for the Locator website. Residential Care Services Investigation Summary Report Provider/Facility: Bonaventure of Vancouver Provider Type: Assisted Living Facility License/Cert.#: 2535 Intake ID: 103533 Compliance Determination #: 32221 Region/Unit #: RCS Region 3 / Unit I Investigator: Richard Westom Investigation Date(s): 11/08/2023 through 11/13/2023 Complainant Contact Date(s): Allegation(s): 1.Pharmaceutical services. Resident missed scheduled medications Investigation Methods: Sample: Total residents: 116 Resident sample size: 3 Closed records sample size: 0 Observations: Identified resident Residents Resident rooms Staff to resident interactions Resident to resident interactions Medication administration Interviews: Identified resident Nursing staff Residents Family members Record Reviews: Medical records Incident investigation Facility policies Investigation Summary: 1. Pharmaceutical services. The facility failed to reorder residents medication resulting in five days of missed medications for one of three residents reviewed. Failed practice. 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. This document was prepared by Residential Care Services for the Locator website. 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, WA 98504-5600 May 16, 2023 ELECTRONIC-FACSIMILE Administrator Bonaventure of Vancouver 9317 NE 86th Street Vancouver, WA 98662 Assisted Living Facility License #2535 Licensee: Bonaventure of Vancouver LLC IMPOSITION OF CIVIL FINES Dear Administrator: On May 4, 2023, the Department of Social and Health Services (DSHS), Residential Care Services completed a Full Inspection at your facility. This letter constitutes formal notice of civil fines on the license for your assisted living facility, also known as Bonaventure of Vancouver, located at 9317 NE 86th Street, Vancouver, 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 fines on the license are based on the following violation of the RCW and/or WAC as described in the attached Statement of Deficiencies (SOD) report dated May 4, 2023. Civil Fines WAC 388-78A-2290 (3)(b)(c) Family assistance with $300.00 medications and treatments. The licensee failed to ensure the written plan for family medication assistance included the minimum information required when two residents had family assisting with medications. This failure placed these residents at risk for not receiving medications as prescribed due to missing documentation of the assistance family was providing with medications. This is a recurring deficiency previously cited on May 24, 2021. Administrator Bonaventure of Vancouver License #2535 May 16, 2023 Page 2 WAC 388-78A-2665 (1)(2)(3)(4)(5)(6) Resident rights—Notice— $300.00 Policy on accepting medicaid as a payment source. The licensee failed to ensure residents were provided a Medicaid policy for six residents. This failure placed these residents at risk of not being aware of their rights as they pertain to Medicaid. This is a recurring deficiency previously cited on May 24, 2021. WAC 388-78A-2610 (1)(2)(a) Infection control. $500.00 The licensee failed to institute standard infection control practices in the assisted living facility to prevent and limit the spread of infections. This failure placed all residents, staff, and visitors at risk of COVID-19 exposure and other potentially infectious diseases. This is a recurring deficiency previously cited on May 24, 2021. WAC 388-78A-2320 (1)(b) Intermittent nursing services systems. $300.00 The licensee failed to ensure staff were nurse delegated for medication administration and medical treatments. This failure resulted in two residents receiving care by undelegated staff and placed residents at risk for receiving care by undelegated staff. This is a recurring deficiency previously cited on May 24, 2021. WAC 388-78A-2371 (1)(2)(3)(4) Investigations. $300.00 The licensee failed to investigate and document actions and findings for the incidents jeopardizing residents’ health for one resident. This failure resulted in the facility being unable to determine the circumstances of the event, institute, and document appropriate measures to prevent similar situations, and protect the resident during the investigation. This is a recurring deficiency previously cited on May 24, 2021. NOTE: These are the violations, which resulted in the fines; see the attached Statement of Deficiencies for any additional violations. 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. Administrator Bonaventure of Vancouver License #2535 May 16, 2023 Page 3 Return the signed and dated SOD to: Michael Burdick, Field Manager Region 3, Unit I 800 NE 136th Ave Suite 220 Vancouver, WA 98684 Phone: (360) 450-1218/ Fax: (360) 992-7969 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 Formal Administrative Hearing You may contest the civil fines by requesting a formal administrative hearing to challenge the deficiency, which resulted in the civil fines. 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. Administrator Bonaventure of Vancouver License #2535 May 16, 2023 Page 4 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 fines are due to the Office of Financial Recovery twenty-eight (28) calendar days after receipt of this letter. Mail a check for $1,700.00 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, Washington 98507-9501 1-800-562-6114 (extension 45919) 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. If you have any questions, please contact Michael Burdick, Field Manager, at (360) 450-1218. Sincerely, Matt Hauser Compliance Specialist Residential Care Services Enclosure cc: Field Manager, Region 3, Unit I 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 HP

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES Aging and Long-Term Support Administration PO Box 45600, Olympia, WA 98504-5600 July 11, 2023 ELECTRONIC-FACSIMILE Administrator Bonaventure of Vancouver 9317 NE 86th Street Vancouver, WA 98662 Assisted Living Facility License #2535 Licensee: Bonaventure of Vancouver LLC IMPOSITION OF CIVIL FINES Dear Administrator: On July 3, 2023, 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 fines on the license for your assisted living facility, also known as Bonaventure of Vancouver, located at 9317 NE 86th Street, Vancouver, WA 98662, 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 fines on the license are based on the following violation of the RCW and/or WAC as described in the attached Statement of Deficiencies (SOD) report dated July 3, 2023. Civil Fines WAC 388-78A-24642 (1)(2)(3) Background checks—National $300.00 fingerprint background check. The licensee failed to complete a national fingerprint background check for five staff. This failure placed all residents and staff at risk for harm by potentially employing staff with disqualifying criminal conviction(s) or pending charge(s) for a disqualifying crime(s). This is an uncorrected deficiency previously cited on May 4, 2023. Administrator Bonaventure of Vancouver License #2535 July 11, 2023 Page 2 WAC 388-78A-2480 (1)(2) Tuberculosis—Testing—Required. $300.00 The licensee failed to complete tuberculosis (TB) (an infectious bacterial disease that often attacks the lungs) testing on one staff within three days of employment. This failure placed all staff and residents at risk for possible exposure and harm from a communicable disease. This is an uncorrected deficiency previously cited on May 4, 2023. WAC 388-78A-2474 (2)(d) Training and home care aide $300.00 certification requirements. The licensee failed to ensure that two staff had the required first aid and cardiac pulmonary resuscitation (CPR) training certifications. This failure placed all residents at risk for emergency care being provided by untrained staff. This is an uncorrected deficiency previously cited on May 4, 2023. WAC 388-78A-2320 (1)(b) Intermittent nursing services systems. $300.00 The licensee failed to ensure consent was received prior to implementing nurse delegation to eight residents and failed to ensure nursing staff were trained and evaluated prior to providing nurse delegated tasks. This failure placed all residents requiring nurse delegation at risk for harm or injury due to receiving nursing care services by untrained staff. This is an uncorrected deficiency previously cited on May 4, 2023. NOTE: These are the violations, which resulted in the fines; see the attached Statement of Deficiencies for any additional violations. 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. Administrator Bonaventure of Vancouver License #2535 July 11, 2023 Page 3 Return the signed and dated SOD to: Michael Burdick, Field Manager Region 3, Unit I 800 NE 136th Ave Suite 220 Vancouver, WA 98684 Phone: (360) 450-1218/ Fax: (360) 992-7969 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 Formal Administrative Hearing You may contest the civil fines by requesting a formal administrative hearing to challenge the deficiency, which resulted in the civil fines. All hearing requests must be in writing and include: • A copy of this letter; and • A copy of the Statement of Deficiencies. Administrator Bonaventure of Vancouver License #2535 July 11, 2023 Page 4 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 fines are due to the Office of Financial Recovery twenty-eight (28) calendar days after receipt of this letter. Mail a check for $1,200.00 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, Washington 98507-9501 1-800-562-6114 (extension 45919) 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 Vancouver License #2535 July 11, 2023 Page 5 If you have any questions, please contact Michael Burdick, Field Manager, at (360) 450-1218. Sincerely, Matt Hauser Compliance Specialist Residential Care Services Enclosure cc: Field Manager, Region 3, Unit I 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 HP

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES Aging and Long-Term Support Administration PO Box 45600, Olympia, WA 98504-5600 September 7, 2023 ELECTRONIC-FACSIMILE Administrator Bonaventure of Vancouver 9317 NE 86th Street Vancouver, WA 98662 Assisted Living Facility License #2535 Licensee: Bonaventure of Vancouver LLC IMPOSITION OF CIVIL FINE Dear Administrator: On August 29, 2023, 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 Vancouver, located at 9317 NE 86th Street, Vancouver, 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 August 29, 2023. Civil Fine WAC 388-78A-2484 Tuberculosis — Two step skin testing. $300.00 The licensee failed to complete tuberculosis (TB) (an infectious bacterial disease that often attacks the lungs) testing on three staff as required. This failure placed all staff and residents at risk for exposure and harm from a communicable disease. This is an uncorrected deficiency previously cited on July 3, 2023. NOTE: This is the violation, which resulted in the fine; see the attached Statement of Deficiencies for any additional violations. Administrator Bonaventure of Vancouver License #2535 September 7, 2023 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: Michael Burdick, Field Manager Region 3, Unit I 800 NE 136th Ave Suite 220 Vancouver, WA 98684 Phone: (360) 450-1218/ Fax: (360) 992-7969 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 Vancouver License #2535 September 7, 2023 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, Washington 98507-9501 1-800-562-6114 (extension 45919) 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 Vancouver License #2535 September 7, 2023 Page 4 If you have any questions, please contact Michael Burdick, Field Manager, at (360) 450-1218. Sincerely, Matt Hauser Compliance Specialist Residential Care Services Enclosure cc: Field Manager, Region 3, Unit I 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 HP